Payers and Managed Care Entities Permission Request Form

Please complete this form to submit a permission request.

 

Contact Information

Address

 

Reason for request

Do you represent a managed care organization?

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

https://www.asam.org/copyright-and-permissions/the-asam-criteria-copyright-and-permissions-forms/asam-criteria-for-utilization-review-and-management