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Chronic Opioid Request Form

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
F252-091-000


 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.



Form
F800-116-000


 
Opioid Treatment Agreement

Use this treatment agreement when starting chronic opioid therapy. It should be renewed yearly or when there is a new prescriber.



Form
F252-095-000



Alt Language(s):
Español
 
Subacute Opioid Request Form

Use this form to request opioid coverage between 6 weeks to 12 weeks from the date of injury or surgery.



Form
F252-097-000


 
Crime Victims Compensation Subacute Opioid Request Form
Use this form for Crime Victims Compensation to request opioid coverage between 6 weeks and 12 weeks from date of injury or surgery.


F800-119-000


 





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