ASAM Pharmacy, Payer, and Other Issues Reporting Form

Reporter Information

Please provide the basic details below. Once you select the issue you are reporting from the drop-down menu under question #9, the correct form for submission will populate.

Please submit one report for each separate issue.

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* 1. Please provide your name.

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* 2. Please list your email address.

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* 3. Are you a member of ASAM?

Yes

I don’t know

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* 4. Best daytime phone number?

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* 5. Organization / practice name?

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* 6. What is your practice type?

Intensive outpatient (non-OTP)

Academic

Government

Community Mental Health Center (CMHC)

Certified Community Behavioral Health Clinic (CCBHC)

Outpatient (OTP)

Residential treatment center

FQHC/RHC

Hospital

Intensive outpatient (OTP)

Community health center

Outpatient (non-OTP)

Other

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* 7. What is the address of the practice where you are reporting an issue?

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* 8. Practice geographic setting?

Urban

Suburban

Rural

ASAM Pharmacy, Payer, and Other Issues Reporting Form

Reporter Information

Question Title

* 1. Please provide your name.

Question Title

* 2. Please list your email address.

Question Title

* 3. Are you a member of ASAM?

Question Title

* 4. Best daytime phone number?

Question Title

* 5. Organization / practice name?

Question Title

* 6. What is your practice type?

Question Title

* 7. What is the address of the practice where you are reporting an issue?

Question Title

* 8. Practice geographic setting?

Question Title

* 9. Which type(s) of issue are you reporting? Please submit a form for each issue you are reporting.