Medical Assisted Treatment (MAT) Request Form

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

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 () -