Patient Enrollment Form PDF Details

In the healthcare journey, particularly in the branches of addiction treatment and recovery, the integration of medication-assisted therapies has been a beacon of hope for many. A quintessential part of initiating such treatment involves comprehensive and meticulous patient enrollment, a crucial first step underscored by the Patient Enrollment form for VIVITROL® (naltrexone for extended-release injectable suspension). This form is not merely a collection of patient details but rather a bridge connecting patients with the necessary care to battle alcohol or opioid dependence, under the vigilant guidance of their healthcare providers. It encompasses essential sections starting from prescriber and injection provider information to detailed patient insurance, diagnosis, and authorization segments, reminding all involved of the gravity and sensitivity of the treatment process. With spaces dedicated for prescriber attestation and patient or legal representative authorization, the form not only adheres to legal prerequisites but also fosters a transparent and trust-building process between the patient and healthcare professionals. Furthermore, it intricately balances the need for thoroughness with the urgency of reducing processing delays, echoing the immediacy and importance of timely care in the journey towards recovery. Each segment of the form, whether it be the diagnosis codes or the consent for the release and use of health information, collectively serves the aim of streamlining the path to treatment initiation, making it a vital document in the realm of addiction medicine.

QuestionAnswer
Form NamePatient Enrollment Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesvivitrol2gether patient assistance form, ontario patient entollment and consent form pdf, patient enrollment, vivitrol enrollment form

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PATIENT ENROLLMENT

FAX COMPLETED FORM TO: 1-877-329-8484

TOUCHPOINTS PHONE: 1-800-848-4876

PRESCRIBER INFORMATION

Prescriber Name*

Prescriber Tax ID #

DEA #

 

 

 

 

State License #

NPI #

 

 

 

 

Prescriber Phone #

Fax #

 

 

 

 

Facility Name

 

 

 

 

 

Address

 

 

 

 

 

City

State

Zip Code

 

 

 

Staf Contact Name

 

 

 

 

 

Staf Contact Phone #

Staf Contact E-mail

 

 

 

 

PLEASE COMPLETE ALL FIELDS TO AVOID PROCESSING DELAYS

TP ID# (TOUCHPOINTS USE ONLY):___________

INJECTION PROVIDER INFORMATION

Will your oice/facility be injecting VIVITROL?

☐Yes, ALL doses

☐No, please locate an Injection Provider or refer to Provider below Provider Name

Provider Address Provider Phone #

Preferred specialty pharmacy (if applicable)

Special shipping instructions/restrictions

PATIENT INFORMATION

PATIENT INSURANCE INFORMATION

Name (First)

 

(Last)

 

 

 

 

 

Date of Birth

 

Gender ☐ Male

☐ Female

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

Home Phone #

 

Mobile Phone #

 

 

 

 

 

 

Best Day to Call

☐ M ☐ T

☐ W ☐ TH

☐ F

 

 

 

 

 

 

Best Time to Call

☐ Morning

☐ Afternoon

☐ Evening

 

 

 

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

INSTRUCT PATIENT TO LIST ALTERNATE DESIGNEE OR CONTACTS ON PAGE 2.

PATIENT DIAGNOSIS–Please check all that apply (See page 3 for Diagnosis Code Descriptions)

Alcohol Dependence

Opioid Dependence

 

☐ 303.00

☐ 303.91

☐ 304.00

☐ 304.03

☐ 304.72

☐ 303.01

☐ 303.92

☐ 304.01

☐ 304.70

☐ 304.73

☐ 303.90

☐ 303.93

☐ 304.02

☐ 304.71

☐ Other ___________

 

 

 

 

 

Patient has tried and failed the following medication(s):

Please list any known allergies to medications or other substances:

Payment Method ☐ Insured ☐ Paying out-of-pocket

ATTACH A COPY OF BOTH SIDES OF

THE PATIENT'S INSURANCE CARD(S).

IF NOT AVAILABLE, COMPLETE SECTION BELOW.

PRIMARY INSURANCE

 

Insurance Type ☐ HMO ☐ PPO

☐ Medicaid ☐ Medicare

Carrier Name

 

 

 

Policyholder Name

 

 

 

Relationship to Patient

Carrier Phone #

 

 

Policyholder Employer Name

 

 

 

Policy #

Group ID #

 

 

PHARMACY BENEFIT PLAN (PBM)

 

PBM Name

 

 

 

Policyholder Name

 

 

 

Relationship to Patient

PBM Phone #

 

 

Policyholder Employer Name

 

 

 

Policy #

Group ID #

 

 

Rx BIN #

 

 

 

PRESCRIPTION INFORMATION

Patient Name

 

 

Date

 

 

 

VIVITROL 380 mg x 1 unit Inject 380 mg IM q4 weeks or q1 month

Provider State License #

 

 

 

 

 

 

Reill

times

 

 

 

 

 

 

 

 

 

 

PROVIDER ATTESTATION

* Prescriber signature must be the same as the prescriber name above

 

 

 

 

 

 

Prescriber's Signature

 

 

Date of Signature

 

 

 

 

 

 

 

 

By signing above, I verify that the information provided in thisTouchpoints enrollment form is complete and accurate to the best of my knowledge. I understand that Alkermes reserves the right at any time and for any reason, without notice, to modify this Touchpoints enrollment form or to modify or discontinue any services or assistance provided throughTouchpoints. Finally, I authorize Alkermes, United BioSource Corporation, Armada Health Care, LLC, and OPUS Health as my designated agents to use and disclosemypatient’shealthinformationasnecessarytoverifytheaccuracyofanyinformationprovided,toprovidereimbursementservicesthroughTouchpoints,toforwardtheaboveprescription,byfaxorothermodeofdelivery,toapharmacyforfulillment, and (as applicable) to assess my patient’s eligibility for co-pay assistance.

PLEASE SEE IMPORTANT SAFETY INFORMATION ON PAGE 4. PLEASE SEE PRESCRIBING INFORMATION

AND MEDICATION GUIDE, OR VISIT VIVITROL.COM. PLEASE REVIEW MEDICATION GUIDE WITH PATIENTS.

PAGE 1

PATIENT ENROLLMENT

PATIENT REPRESENTATIVE

By signing below, I authorize my Designee(s), listed below, to receive administrative information related to my treatment, such as appointment reminders, and to make decisions on my behalf—for which I will remain liable—regarding delivery ofVIVITROL® (naltrexone for extended-release injectable suspension). Alkermes is not liable for any decision(s) made by the Designee(s) or actions taken in reliance on such Designee(s) decisions.

Please list any Designees authorized to receive administrative information related to my treatment:

Designee Name (1)

Relationship

 

Phone #

 

 

 

 

 

Designee Name (2)

Relationship

 

Phone #

 

 

 

 

 

 

 

 

 

 

Patient's Signature

 

Date of Signature

 

 

 

 

 

 

 

PATIENT AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

Bysigningbelow,Iauthorize:1.myprescribingphysician,2.thehealthcareproviderdesignatedtoadministerVIVITROLtome(“AdministeringHCP”),

3.oneormorenetworkspecialtypharmacies†,Cardinal3PL,UnitedBioSourceCorporation,IntouchSolutions,OPUSHealth,ArmadaHealthCare,LLC, and4.AlkermestouseanddisclosetoeachotherandtomyDesignee(s),listedabove,mymedicalorotherinformationsetforthonthefirstpageof thisform,includinginformationaboutmytreatmentwithVIVITROL(takentogether,“Information”)forthespecificpurposesof:

1.ordering,delivering,andadministeringVIVITROL,2.conductingreimbursementverificationandobtainingpaymentfrommyHealthPlan(s),

3.providingmewitheducationalandtherapysupportservicesbymail,text-messaging,e-mail,and/ortelephoneand4.referringmeto,or determiningmyeligibilityfor,otherprograms,foundationsoralternativesourcesoffundingorcoveragetohelpmewiththecostsofVIVITROL.I understandthatsupportservicesmayincludeproductinformationmaterialsandtreatmentreminders. InformationMayBeFurtherDisclosed:I understandthatINFORMATIONdisclosedpursuanttothisauthorizationcouldbere-disclosedbyarecipientandmaynolongerbeprotectedbyfederal privacylaw(HIPAA).ForCaliforniaResidents:Californialawprohibitsthepersonreceivingyourhealthinformationfrommakingfurtherdisclosureof it,unlessanotherauthorizationforsuchadditionaldisclosureisobtainedfromyouorunlesssuchdisclosureisspecificallyrequiredorpermittedbylaw.

IunderstandthatsigningthisauthorizationisvoluntaryandifIdonotsignthisauthorizationitwillnotaffectmyabilitytoobtaintreatmentfrom myprescribingphysicianorobtaininsuranceorinsurancebenefits.Iunderstand,however,thatifIdonotsignthisauthorization,Iwillnotbeeligible toreceivetheeducational,supportorotherservicesdescribedabove.IunderstandIhavetherighttoreceiveacopyofthisauthorizationafterIsign.I understandthatthedisclosureofmyInformationmayresultinremunerationtooneormorenetworkspecialtypharmacies.IunderstandthatImay seeacopyoftheinformationdescribedinthisauthorizationifIrequesttodoso.

ImaywithdrawthisauthorizationatanytimebymailingorfaxingawrittenrequesttoTouchpointsReimbursementSupport,1670CenturyCenter Parkway,Memphis,TN38134orbycalling1-800-VIVITROL.WithdrawalofthisauthorizationwillendfurtherusesanddisclosuresofmyInformation bythepartiesidentifiedinthisauthorizationexcepttotheextentthoseusesanddisclosureshavebeenmadeinrelianceuponthisauthorizationandas permittedbyapplicablelaw.ThisauthorizationexpiresfiveyearsfromthedateindicatedbelowunlessIwithdrawitearlier.

Patient's Signature Date of Signature

Parent/Guardian/Legal Representative’s Signature§

Authority/Relationship to Patient

 

 

☐(Checkif"yes") I would like to receive co-payment assistance from Alkermes. I certify that I am at least 18 years old, I am being treated for opioid dependence after detox or alcohol dependence and that myVIVITROL prescription will NOT be purchased under Medicaid, Medicare,TRICARE®, or any federal or state healthcare program, including any state medical or pharmaceutical assistance program.‡

† See page 3 for a list of Network Specialty Pharmacies.

‡Eligibility for Sponsored Co-pay Assistance: Ofer valid for prescriptions for FDA-approved indications. Patients must be at least 18. Ofer not valid for prescriptions purchased under Medicaid, Medicare, TRICARE® or any other federal or state healthcare program, including any state medical or pharmaceutical assistance program. Void where prohibited by law, taxed or restricted. Alkermes, Inc. reserves the right to rescind, revoke or amend these ofers without notice.

§ If patient is a minor without capacity to act alone under state law, signature of patient and parent/guardian/legal representative is required.

PLEASE SEE IMPORTANT SAFETY INFORMATION ON PAGE 4. PLEASE SEE PRESCRIBING INFORMATION AND MEDICATION GUIDE, OR VISIT VIVITROL.COM. PLEASE REVIEW MEDICATION GUIDE WITH PATIENTS.

VIV-001548

PAGE 2

PATIENT ENROLLMENT

INJECTION PROVIDER SELECTION INFORMATION (AS APPLICABLE)

If you have requested injection services for your patient, Touchpoints will provide a selection of several injectors based on geographic proximity to your patient’s address listed on the enrollment form (from closest to farthest from such address).

These injection providers are listed on the VIVITROL Provider Locator ll at www.VIVITROL.com.

These options will be provided to you for your patient. We will also contact the selected injection services provider to help coordinate injection services.

llEnrollment in the Locator is voluntary and free of charge and, along with the provider-speciic information in the Provider Locator, is based on healthcare provider responses. Inclusion in the Locator does not imply a referral, recommendation or endorsement by Alkermes. Alkermes has not independently veriied the qualiications of any healthcare provider included in the Locator. We recommend that you research the credentials, qualiications, and experience of each provider before conirming an appointment. Alkermes shall not be liable to you or to anyone for any decision made or action taken in reliance on this information.

DIAGNOSIS CODE DESCRIPTIONS

Alcohol Dependence

Opioid Dependence

303.00

Acute alcoholic intoxication, unspeciied drunkenness

304.00

Opioid type dependence, unspeciied abuse

303.01

Acute alcoholic intoxication, continuous drunkenness

304.01

Opioid type dependence, continuous abuse

303.90

Other and unspeciied alcohol dependence, unspeciied drunkenness

304.02

Opioid type dependence, episodic abuse

303.91

Other and unspeciied alcohol dependence, continuous drunkenness

304.03

Opioid type dependence, in remission

303.92

Other and unspeciied alcohol dependence, episodic drunkenness

304.70

Combinations of opioid type drug with any other drug dependence, unspeciied abuse

303.93

Other and unspeciied alcohol dependence, in remission

304.71

Combinations of opioid type drug with any other drug dependence, continuous abuse

 

 

304.72

Combinations of opioid type drug with any other drug dependence, episodic abuse

 

 

304.73

Combinations of opioid type drug with any other drug dependence, in remission

 

 

 

 

NETWORK SPECIALTY PHARMACIES

Accredo Health Group, Inc.; Acro Pharmaceutical Services; Aetna Specialty Pharmacy®; Avanti Health Care; Avella Inc.; BriovaRx™; CareSite Pharmacy; CarePlus Pharmacy; Chartwell Pennsylvania, LP; Cigna; Commcare Pharmacy; Coram LLC; Costco Health Solutions; CuraScript, Inc.; CVS Caremark; Diplomat Pharmacy; Pharmacy Solutions; Fairview Health Services; Humana; Kelley-Ross & Associates Inc.; The Kroger Company; LDI; LegacyRx™; Lovelace Health System; Magellan Health Services, Inc.; Medicine Shoppe International, Inc.; MedVantx Inc.; OptumRx, Inc.; Orchard Pharmaceutical Services; Orsini Healthcare; Pharmacy Advantage; Prime Therapeutics LLC; Providence Health & Services; Reliance Rx; Reliant Healthcare; Restore RX. inc.; Transition Pharmacy Services; US Specialty Care®; Vital Care Rx; Walgreen Co.

PLEASE SEE IMPORTANT SAFETY INFORMATION ON PAGE 4. PLEASE SEE PRESCRIBING INFORMATION AND MEDICATION GUIDE, OR VISIT VIVITROL.COM. PLEASE REVIEW MEDICATION GUIDE WITH PATIENTS.

PAGE 3

PATIENT ENROLLMENT

IMPORTANT SAFETY INFORMATION FOR VIVITROL® (naltrexone for extended-release injectable suspension)

INDICATIONS

VIVITROL is indicated for:

•Treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting. Patients should not be actively drinking at the time of initial VIVITROL administration.

•Prevention of relapse to opioid dependence, following opioid detoxiication.

•VIVITROL should be part of a comprehensive management program that includes psychosocial support.

CONTRAINDICATIONS

VIVITROL is contraindicated in patients:

•Receiving opioid analgesics

•With current physiologic opioid dependence

•In acute opioid withdrawal

•Who have failed the naloxone challenge test or have a positive urine screen for opioids

•Who have exhibited hypersensitivity to naltrexone, polylactide-co-glycolide (PLG), carboxymethylcellulose, or any other components of the diluent

WARNINGS/PRECAUTIONS

Vulnerability to Opioid Overdose: Because VIVITROL blocks the effects of exogenous opioids for approximately 28 days after administration, patients are likely to have a reduced tolerance to opioids after opioid detoxiication. As the blockade dissipates, use of previously tolerated doses of opioids could result in potentially life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc). Cases of opioid overdose with fatal outcomes have been reported in patients who used opioids at the end of a dosing interval, after missing a scheduled dose, or after discontinuing treatment. Patients and caregivers should be told of this increased sensitivity to opioids and the risk of overdose.

Any attempt by a patient to overcome the VIVITROL blockade by taking opioids may lead to fatal overdose. Patients should be told of the serious consequences of trying to overcome the opioid blockade.

Injection Site Reactions: VIVITROL injections may be followed by pain, tenderness, induration, swelling, erythema, bruising, or pruritus; however, in some cases injection site reactions may be very severe. Injection site reactions not improving may require prompt medical attention, including, in some cases, surgical intervention. Inadvertent subcutaneous/adipose layer injection of VIVITROL may increase the likelihood of severe injection site reactions. Select proper needle size for patient body habitus, and use only the needles provided in the carton. Patients should be informed that any concerning injection site reactions should be brought to the attention of their healthcare provider.

Precipitation of Opioid Withdrawal: Withdrawal precipitated by administration of VIVITROL may be severe. Some cases of withdrawal symptoms have been severe enough to require hospitalization and management in the ICU. To prevent precipitated withdrawal, patients, including those being treated for alcohol dependence:

•Should be opioid-free (including tramadol) for a minimum of 7–10 days before starting VIVITROL.

•Patients transitioning from buprenorphine or methadone may be vulnerable to precipitated withdrawal for as long as two weeks.

Patients should be made aware of the risk associated with precipitated withdrawal and be encouraged to give an accurate account of last opioid use.

Hepatotoxicity: Cases of hepatitis and clinically signiicant liver dysfunction have been observed in association with VIVITROL. Warn patients of the risk of hepatic injury; advise them to seek help if experiencing symptoms of acute hepatitis. Discontinue use of VIVITROL in patients who exhibit acute hepatitis symptoms.

Depression and Suicidality: Alcohol- and opioid-dependent patients taking VIVITROL should be monitored for depression or suicidal thoughts. Alert families and caregivers to monitor and report the emergence of symptoms of depression or suicidality.

When Reversal of VIVITROL Blockade Is Required for Pain Management: For VIVITROL patients in emergency situations, suggestions for pain management include regional analgesia or use of non-opioid analgesics. If opioid therapy is required to reverse the VIVITROL blockade, patients should be closely monitored by trained personnel in a setting staffed and equipped for CPR.

Eosinophilic Pneumonia: Cases of eosinophilic pneumonia requiring hospitalization have been reported. Warn patients of the risk of eosinophilic pneumonia and to seek medical attention if they develop symptoms of pneumonia.

Hypersensitivity Reactions: Patients should be warned of the risk of hypersensitivity reactions, including anaphylaxis.

Intramuscular Injections: As with any IM injection, VIVITROL should be administered with caution to patients with thrombocytopenia or any coagulation disorder.

ADVERSE REACTIONS

Serious adverse reactions that may be associated with VIVITROL therapy in clinical use include severe injection site reactions, eosinophilic pneumonia, serious allergic reactions, unintended precipitation of opioid withdrawal, accidental opioid overdose, and depression and suicidality. The adverse events seen most frequently in association with VIVITROL therapy for alcohol dependence include nausea, vomiting, injection site reactions (including induration, pruritus, nodules, and swelling), muscle cramps, dizziness or syncope, somnolence or sedation, anorexia, decreased appetite or other appetite disorders. The adverse events seen most frequently in association with VIVITROL in opioid-dependent patients also include hepatic enzyme abnormalities, injection site pain, nasopharyngitis, insomnia, and toothache.

PLEASE SEE PRESCRIBING INFORMATION AND MEDICATION GUIDE, OR VISIT VIVITROL.COM.

PLEASE REVIEW MEDICATION GUIDE WITH PATIENTS.

Alkermes® and VIVITROL® are registered trademarks of Alkermes, Inc. Touchpoints is a service mark of Alkermes, Inc.

TRICARE® is a registered trademark of TRICARE Management Activity ©2014 Alkermes, Inc.

All rights reserved

VIV-001548

www.vivitrol.com

 

PAGE 4

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