Get Buprenorphinenaloxone Medication Request Form - Network-health

Filling out the /Naloxone Medication Request Form is an essential step for healthcare providers seeking authorization for this medication. This guide provides a clear and supportive walkthrough of the form's components to ensure accurate and thorough submissions.

Follow the steps to successfully complete the medication request form.

1. Click ‘Get Form’ button to access the medication request form and open it in your document editor.
2. Begin by entering today's date in the specified format at the top of the form.
3. In the member/prescriber information section, fill in the member's name, member ID number, and date of birth. Also, provide the prescriber's name, specialty, DEA number, NPI number, and contact information.
4. Indicate the pharmacy used by the member, including the pharmacy's contact details.
5. Move to the medication information section. Specify the drug name as /Naloxone and select the dosage form from the provided options.
6. Fill in the strength and frequency of the medication along with the duration of the treatment.
7. In the clinical information section, indicate the diagnosis by selecting the appropriate checkbox and provide details if ‘Other’ is selected.
8. Answer the questions regarding the provider's experience with opioid dependency treatments and the member's engagement in a substance abuse treatment program.
9. Confirm that the prescriber is participating in the outlined treatment protocols by checking all applicable boxes.
10. Provide rationale for any dosage that exceeds recommended maintenance doses and include any necessary additional information.
11. Complete any required inquiries related to the request for brand-name medications and any specific patient history.
12. Certify that the information is accurate and complete. Sign the form, ensuring that a manual signature is provided instead of a stamp.
13. Review the completed form, then save your changes, and you may choose to download, print, or share it as necessary.

Complete and submit your /Naloxone Medication Request Form online today.