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  • Va Premier Sublocade Injection Ciii Enrollment Form 2018

Get Va Premier Sublocade Injection Ciii Enrollment Form 2018-2025

242-2241 Fax: 877-342-4596 DEA PATIENT INFORMATION NPI Please complete the following or send patient demographic sheet State License Patient Name XDEA Address DATA 2000 Waiver Address 2 Group/Hospital Address City, State, ZIP Home Phone DOB Alternate Phone Last Four of SS# Language Preference: English Gender Spanish INSURANCE INFORMATION Other City, State, ZIP Phone Fax Contact Person Phone (Fill out entirely or fax a copy of patient s insurance card including both side.

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Prescribers can obtain SUBLOCADE for a specific named patient's scheduled appointment by writing a prescription and sending it to a REMS-certified pharmacy. The REMS-certified pharmacy coordinates delivery to the prescriber or the practitioner administering SUBLOCADE with the patient's appointment date.

These HCPCS G-codes describe treatment with: ● (G2067) ● oral (G2068) ● injectable (G2069) ● implants (insertion, removal, and insertion/removal) (G2070, G2071, and G2072) ● Extended-release, injectable (G2073) ● Non-drug bundle (G2074) • You didn't ...

Age > 18 years and • Diagnosis of Opioid Dependence and • Must not be used in opioid naïve patients, and • Must currently be on a maintenance dose of 8mg to 24 mg per day dose of an oral, sublingual, or transmucosal product equivalent for at least 7 days prior to initiation of extended-release ...

Can someone get SUBLOCADE at a pharmacy? No, SUBLOCADE is not available in retail pharmacies. SUBLOCADE must be prescribed, obtained, and administered by a healthcare provider. If the healthcare provider practices in an office‑based setting, then he/she must be waivered to prescribe SUBLOCADE.

SUBLOCADE is available in dosage strengths of 100 mg/0.5 mL and 300 mg/1.5 mL . Each dose is a clear, colorless to yellow to amber solution provided in a prefilled syringe with a 19 gauge 5/8- inch needle.

Only treatment providers who have gone through specific training can become waivered to prescribe and administer medications that contain to treat opioid addiction in an office-based setting. Waivered SUBLOCADE treatment providers can be doctors, physician assistants, or nurse practitioners.

HCPCS code Q9992 for Injection, extended-release (sublocade), greater than 100 mg as maintained by CMS falls under Other Drugs and Test.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232