Chronic Opioid Request Form

Chronic Opioid Request Form - (Forms/Publications)
Document Information
  Get help downloading & printing files.   How to complete a fillable form.
Title Chronic Opioid Request Form (A fillable form - 169 KB PDF)

Use this form to request opioid coverage beyond 12 weeks from the date of injury or surgery, or every 90 days for chronic opioid therapy.

Form number F252-091-000
Order it
Keywords chronic noncancer pain, opioids, pain management, preauthorization, request
Languages English
Valid dates 07-2013
Contact information   - 360-902-5762 -
Office of the Medical Director

End of main content, page footer follows.

Access Washington official state portal

© Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.