Vivitrol Enrollment Form (Download Fillable PDF)
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Vivitrol Enrollment Form |
Patient Support Program |
05 Pages |
PDF, Fillable PDF |
Vivitrol Enrollment Form
Starting treatment with Vivitrol requires more than just a prescription. It requires proper coordination, insurance verification, and patient support, ensuring the patients receive everything smoothly without unnecessary delays. The Vivitrol enrollment form makes this process easier for the patients and healthcare providers by collecting all necessary information in one place. By completing this form, patients can access benefit verification, pharmacy coordination, Vivitrol copay assistance (if eligible), and additional support services. To avoid treatment delays, download, fill out, and submit the enrollment form today.
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Benefits of The Vivitrol Patient Enrollment Form
Co-Pay Assistance Program
The commercially insured eligible patients qualify for financial assistance through Vivitrol’s co-pay assistance. It significantly reduces out-of-pocket costs, making therapy more affordable.
Transition of Care Assistance
If the patient changes treatment provider or facilities, Vivitro Together representatives can coordinate the transition. This prevents interruptions and helps the patient stay on track with treatment.
Access to Educational Resources
The enrolled patients and providers can receive access to the official Vivitrol medication guide and updates. They get educational material related to their medication and treatment.
Key Sections of The Vivitrol Together Enrollment Form
Prescriber Information
This section includes the prescriber’s information, including their name, specialization, address, state license number, and facility details.
Patient Information
It includes the patient’s demographics, contact information, identifiers, etc.
Diagnosis Information
The section describes appropriate diagnosis codes, prior treatment history, current medication, and any known allergies.
Insurance Details
The insurance section describes primary and secondary insurance, the pharmacy group, and other information related to the insurer.
Prescription Information
It contains specific prescription details, such as dosage, frequency, and pharmacy preference.
Support Services
This section allows prescribers to select support services, including benefits verification, pharmacy routing, injection-site care, transition of care coordination, and a co-pay program.
Shipping Authorization
It authorizes medication delivery to the provider’s office.
How To Complete The Vivitrol Enrollment Form PDF?
Choose Required Program: Choose a program offering that best meets the patient’s needs, such as Vivitrol2Gether, Transition of Care Services, Benefits Verification, or Buy & Bill Benefits Verification.
Prescriber or Faculty Information: Write the complete prescriber’s name, tax ID, state license number, NPI, PTAN, facility name, address, contact details, and staff information.
Patient Information: Fill in the patient’s name, address, date of birth, gender, email address, and contact details.
Diagnosis: Indicate the primary diagnosis, ICD-10 codes, prior medication, and current medication information.
Transition of Care Coordination: Specify the patient’s estimated discharge date, dosage, and frequency. Also, indicate the preferred dosing site.
Insurance Details: Select the payment method and insurance type, then attach the front and back copies of the insurance card(s). Also, write the insurance name, policyholder name, PA number, policyholder employer name, policy number, group ID, pharmacy benefit plan (PBP) name, PCN, BIN, etc.
Prescription Information: Fill in the dosage, directions, number of refills, preferred pharmacy name, provider’s state license number, and prescriber’s signature.
Designated Patient Contact: Write the designee’s name, their relationship with the patient, address, and phone number.
Copay Saving Program & Signature: By signing this section, the commercially insured eligible patients certify that they are not receiving any Medicare, Medicaid, Tricare, Medigap, etc., medication costs.
Shipping Authorization: The commercially insured patient must sign and date this section to authorize the pharmacy to communicate with their healthcare provider regarding the delivery of Vivitrol2gether medication.
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Frequently Asked Questions
What is the purpose of the Vivitrol enrollment form?
This form connects patients and providers with the VIVITROL2GETHER support programs, providing access to insurance verification, copay savings, patient assistance programs, and other support services.
Can I cancel my authorization?
The patients can cancel their authorization at any time by submitting a written cancellation request. However, once revoked, some program services may no longer be available.
Can Vivitrol be shipped directly to my home?
The Vivitrol can never be shipped directly to the patient’s home. For eligible patients, it may be shipped to the prescribing provider’s office.
What documents do I need to include?
It requires front and back copies of the insurance card, prescription information, and the prescriber’s details, which must be attached.
How do I submit the form?
Once completed and signed, the form should be faxed. Keep a copy for your records.
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