Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the member information section. Enter the member's full name, date of birth, and insurance ID number. Ensure that all fields are accurately completed to avoid processing delays.
3. Proceed to the provider information section. Fill in the provider's name, National Provider Identifier (NPI) number, office phone number, fax number, and the office address, including street, city, state, and zip code.
4. In the medication information section, input the name of the medication, its strength, dosage form, and directions for use. Indicate whether this medication is a new start by checking 'Yes' or 'No.'
5. Next, focus on the clinical information. Select the diagnosis from the options provided (treatment of opioid dependence or other). If you select 'other,' ensure to provide the required ICD-9/10 code(s).
6. Indicate whether there is documentation for the patient’s participation in addiction counseling by selecting 'Yes' or 'No.'
7. For quantity limit requests, state the quantity requested per day and explain the reason for exceeding plan limitations by choosing applicable options or providing other relevant information.
8. Include any additional comments or information that may assist in the review process, such as other diagnoses or medications tried.
9. After reviewing all entries for accuracy, save your changes. You can then download, print, or share the completed form as needed.

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