Medical Assisted Treatment (MAT) Request Form

  1. Clinician Information
  2. Patient Information
  3. Clinical Information

Fields marked with an asterisk are required. The certification is not valid until CBA issues a certification number.

Please indicate if this is:

Step One - Clinician & Facility Information

Clinician Information

Outpatient clinics please use same NPI for both fields.

Phone () -
Fax () -
Facility Information
Phone () -