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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How to fill out the VA Premier Sublocade Injection CIII Enrollment Form online
Filling out the VA Premier Sublocade Injection CIII Enrollment Form online is an essential step for prescribers looking to ensure the proper administration of Sublocade for patients. This guide provides clear instructions to help you complete the form accurately and efficiently.
Follow the steps to complete your enrollment form.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Fill out the prescriber information section. This includes the prescriber’s name, address, phone number, fax number, DEA, and NPI.
- Provide patient information. Enter the patient's name, address, date of birth, home phone number, and alternate phone number. Include the last four digits of the patient's Social Security number and language preference.
- Complete the insurance information section. This necessitates filling out the insurance details entirely or attaching a copy of the patient’s insurance card.
- In the medical information section, include the diagnosis with the corresponding ICD-10 code, any allergies, concomitant medications, weight, height, and BMI.
- Move on to the prescription information. Fill in the medication name, dose/strength, directions, quantity, and refills. Be mindful that only one prescription can be written per blank.
- Provide office contact and shipping information. Enter the contact person's name, phone number, shipping address, and the date the medication is needed.
- Make sure to sign and date the form manually, as electronic signatures are not accepted.
- Once all fields are completed, review the form for accuracy. Users can now save changes, download, print, or share the form as needed.
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How do I order Sublocade?
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.
What is the Hcpcs code for injection?
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 ...
Who qualifies for Sublocade?
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 you get Sublocade at pharmacy?
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.
How is Sublocade supplied?
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.
Can anyone prescribe Sublocade?
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.
What is the injection code for Sublocade?
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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