Sublocade Specialty Form

P:270-937-9008
www.staywellathometown.com
SURESCRIPT #: 1840203

Patient Name*

SS#*

Date of Birth*

DayMonthYear

Language Preference*

Other Language Preference*

Type a question*

MaleFemale

Phone Number*

Address*

Prescriber Name

Prescriber DEA

Prescriber NPI

Prescriber State License

Prescriber XDEA

Group / Hospital Name

Group / Hospital Address

Group / Hospital Phone

Medical Information & Insurance

Please Upload a Copy of Patient's Insurance Card (front and back)

Prior Authorization Reference Number

Diagnosis (ICD10 Code)

F11.20 Opioid Dependence, uncomplicated

F11.21 Opioid Dependence, in remission

Other: ICD-10

Other: Description

Height

Weight

BMI

Allergies to medications

Concomitant Medications (Fill out completely or Fax Med List)

PRESCRIPTION USE OF THIS PRODUCT IS LIMITED BY THE DRUG ADDICTION TREATMENT ACT (DATA) TOPRESCRIBERS WHO ARE AUTHORIZED TO TREAT OPIOID DEPENDENCE AND ARE DATA 2000 WAIVER AND DEA ISREGISTERED TO THE SITE THE INJECTION WILL BE ADMINISTERED.
SUBLOCADE MAY ONLY BE DELIVERED TO A HEALTHCARE SETTING AND IS NEVER DISPENSED DIRECTLY TO THEPATIENT
SUBLOCADE MAY ONLY BE OBTAINED THROUGH REMS-CERTIFIED PHARMACIES; PLEASE VISIT WWW.SUBLOCADEREMS.COM FOR MORE INFORMATION
ALL PRESCRIPTIONS FOR SUBLOCADE SHOULD BE SENT DIRECTLY TO THE REMS-AUTHORIZED DISPENSINGPHARMACY, FOR PATIENT SUPPORT AND PROGRAM INFORMATION, PLEASE VISIT THE MANUFACTURER’SPRODUCT SUPPORT

Office Contact*

Office Contact Phone*

Shipping Address*

Date Medication is Needed*

MonthDayYear

This form is provided as a convenience to prescribers. Please send prescriptions for Sublocad eelectronically to the pharmacy and a representative from our clinical pharmacy staff will reach out to schedule shipping or drop off for patient prescription delivery.

Confidentiality Statement: This communication is intended for use of the individual or entity to which it is addressed and may contain information that is privileged, confidential, and exempt from disclosure under applicable law. If the reader of this communication is not the intended recipient or agent responsible for delivery of the communication, you are hereby notified that any dissemination, distribution, or copying of the communication is strictly prohibited. If you have received in error, please notify us immediately by phone.

Sublocade Specialty Form

Patient Information / Prescriber Information