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? (Required.)

Intensive outpatient (OTP)

FQHC/RHC

Outpatient (non-OTP)

Certified Community Behavioral Health Clinic (CCBHC)

Community Mental Health Center (CMHC)

Intensive outpatient (non-OTP)

Residential treatment center

Hospital

Academic

Community health center

Government

Outpatient (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? (Required.)

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* 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. (Required.)

1. Please provide your name.

2. Please list your email address.

3. Are you a member of ASAM?

4. Best daytime phone number?

5. Organization / practice name?

6. What is your practice type? (Required.)

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

8. Practice geographic setting?

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