Payers and Managed Care Entities Permission Request Form

Payers and Managed Care Entities Permission Request Form

First Name

Last Name

Organization

Phone

Street Address

Street Address Line 2

City

State

Zip Code

Country

Do you represent a managed care organization?

Yes

Please indicate the states in which you would like to implement The ASAM Criteria

Number of licenses desired (i.e., the number of employees or contractors that will use The ASAM Criteria)

The license granted is limited to the number of end-users and covered lives specified in the licensing agreement. At the following link:

Number of covered lives

New code

Please type the code above