This site is intended for US patients

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INSUPPORT for Patients
Learn more about how to enroll with INSUPPORT

Getting started is simple

Patient Enrollment Form

In order to initiate any services with INSUPPORT™, you and your healthcare provider must complete the required sections of the form and your healthcare provider will submit the completed Patient Enrollment Form for you.

If you choose not to enroll in INSUPPORT™, you can still be treated with SUBLOCADE™ (buprenorphine extended-release) injection, for subcutaneous use (CIII). You may choose to enroll or discontinue use of INSUPPORT™ services at any time.

Download Patient Enrollment Form
English form Spanish form

If you require assistance in other languages, then please call INSUPPORT™ at 1-844-INSPPRT (1-844-467-7778).

Need help completing the form? See a sample form now

English form

Patient Authorization and Consent Form

This form is included as a part of the Patient Enrollment Form. Your signed and dated Patient Authorization and Consent Form allows your healthcare provider to share your personal health information with INSUPPORT™ and other listed entities that will assist in completing your service request.

You must fill out the Patient Authorization and Consent Form yourself. Include your name, your healthcare provider's name, and the Case ID provided by your healthcare provider (located at the top of the Patient Authorization and Consent page). You may choose to enroll or discontinue use of INSUPPORT™ services at any time.

In the event your signature was not captured on the Patient Authorization and Consent Form in your healthcare provider's office, you may also download the form and submit it yourself.

Download Patient Authorization and Consent Form
English form

If you require assistance in other languages, then please call INSUPPORT™ at 1-844-INSPPRT (1-844-467-7778).

There are two ways to submit your form: Fax it to INSUPPORT™ at 1-844-814-0669 or send electronically via the INSUPPORT™ Patient Portal.

IMPORTANT TO REMEMBER:

Read, understand, sign, and date the bottom of the Patient Authorization and Consent Form. You may revoke your consent by contacting INSUPPORT™ at any time. You must read, understand, sign, and date the consent form in order to receive any services from INSUPPORT™.

The Patient Portal

The INSUPPORT™ Patient Portal allows web-based personal monitoring of case and copay activity, where applicable.

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