Transcription of Provider Authorization & Confidentiality Agreement
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Provider Authorization & Confidentiality Agreement
ALKERMES and VIVITROL are registered trademarks of Alkermes, Inc. Vivitrol2gether is a service mark of Alkermes, Inc. 2019 Alkermes, Inc. All rights reserved VIV-004800 M-F, 9:00 AM to 8:00 PM ET 1-800-VIVITROL (1-800-848-4876) 1 Provider Authorization & Confidentiality Agreement (* denotes required information) This form must be completed by the Prescriber or Medical Director at the facility requesting access to the Vivitrol2getherSM Patient Support Services Portal. PLEASE PRINT ALL INFORMATION CLEARLY. Facility Information *Pr escribing Physic ian Name: *Pr escriber State License Number: *Prescriber Email: *Facility Name: *Facility Address: *Cit y: *State: *Zip: *Facility Phone Number: Medical Director Name (if applicable ): I, , hereby request access to the Vivitrol2getherSM Patient Support Servi ces Portal ( Portal ).
2 ALKERMES and VIVITROL are registered trademarks of Alkermes, Inc. Vivitrol2gether is a service mark of Alkermes, Inc. ©2017 Alkermes, Inc.
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