Chronic Opioid Request Form

Document Information
  How to complete a fillable form.
Title 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.

Document number F252-091-000
How to get this document
Alt Language(s)
Valid dates 01/2015
Contact information Office of the Medical Director
Websites Prescribing Opioids to Treat Pain in Injured Workers

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