Jail Dosing Inquiry Form

Jail Dosing Inquiry Form
Please fill out this form if you are looking to coordinate MAT medication continuation for an existing BrightView patient during incarceration. In addition to this form, you will also need to complete a Release of Information for the patient. Upon submission, a member of our team will reach out to coordinate.
PATIENT INFORMATION
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State
Kentucky Center
Maryland Center
North Carolina Center
Ohio Center
Virginia Center
Start Date of Incarceration

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expected Lenth of Incarceration (if known):
INCARCERATION FACILITY INFORMATION
Name of Incarceration Facility:
Name of Primary Contact:
Preferred Method of Contact:
Contact Phone Number:
Format: (000) 000-0000.
Contact E-mail:
example@example.com
Is the incarceration facility contracted with a 3rd party OTP/NTP to facilitate medication administration? Note: additional ROIs will be required for coordinating care with any 3rd party entities.
If yes, name & contact of OTP/NTP:
Are there any other contacts to coordinate care with? (i.e. healthcare coordinators)
Please attach any signed ROIs relevant to coordinating the patient's continued MAT care while incarcerated.

Cancelof
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