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

This form can only be used for services that can be authorized by the claim manager and it should not be used for Utilization Review (Qualis), Provider Hotline or requests to the Occupational Nurse Consultant.  If you are unsure of what services need to be authorized see L&I fee lookup utility.

Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.

Used by the clinical provider to get preauthorization for payment of additional sessions.

Used by the clinical provider to request preauthorization for payment of additional sessions.