Patient Forms
NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) capsules Enrollment Application
New Provider Form ABILIFY MAINTENA® (aripiprazole) Medical Necessity Form
NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) capsules Enrollment Application
ABILIFY MAINTENA® (aripiprazole) Enrollment Application
ABILIFY MAINTENA® (aripiprazole) Refill Request Form
REXULTI® (brexpiprazole) Enrollment Application
New Provider Form REXULTI® (brexpiprazole) Medical Necessity Form
Medical Necessity Letter SAMSCA®(tolvaptan)
New Provider Form SAMSCA®(tolvaptan) Medical Necessity Form
Re-initiation of Therapy Form SAMSCA®(tolvaptan)
SAMSCA®(tolvaptan) Enrollment Application
JYNARQUE® (tolvaptan) Enrollment Application
New Provider Form JYNARQUE® (tolvaptan) Medical Necessity Form
Income Insurance Residency Attestation Letter
Additional Antidepressant Request Form
Vitamins Request Form