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Washington opioid attestation form

Opioid attestation form 2026

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The document outlines the process for prescribers to attest to the chronic use of opioids for patients, detailing criteria that must be met for authorization beyond standard limits. It includes instructions for submitting the attestation form, necessary patient and provider information, and guidelines for pharmacies on billing and documentation. The attestation is valid for a maximum of 12 months unless specified otherwise.

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Click ‘Get Form’ to open the opioid attestation form in the editor.
Begin by entering the patient's information, including their name and date of birth. This is crucial for identifying the individual receiving treatment.
Fill in the pharmacy details, such as the pharmacy name, NPI (if known), telephone number, and fax number. Accurate information ensures smooth communication.
Next, provide prescriber information including their NPI, telephone number, and fax number. This section is vital for authorization purposes.
Indicate the medication and strength prescribed along with any specific directions for use if known. This helps clarify treatment plans.
Review the criteria for chronic opioid use carefully. Ensure that all necessary conditions are met and documented in the medical record.
Sign and date the attestation at the bottom of the form to certify that all information provided is accurate.

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What is an attestation in medicine?

Release of Information (ROI) offices now face new responsibilities: ensuring that medical records are not released for purposes of investigation or punishment. To meet this need, attestationsa formal statement verifying the intent behind a record requestare increasingly required.

What is the difference between an opioid and an ?

While the terms opioids and opiates are sometimes used interchangeably, refers specifically to natural compounds, such as or morphine, while opioids includes both naturally-occurring opiates and those created in a lab.

What is a relief attestation form?

Now if your trip has a flight lasting longer than 8 hours, then you will also need to complete a Service Animal Relief Attestation form. This document verifies that Max can go for 8 hours without needing to relieve himself.

How to write an attestation form?

Drafting Your Letter Address the letter to the appropriate individual or entity. Introduce yourself if appropriate. Identify the person for whom youre writing the letter. Provide the facts or information to which you attest. Include a declaration if youre writing the letter for yourself.

What is an opioid attestation?

This form is required when patients begin chronic use of opioid, when daily opioid doses exceed 120 MME, or when both occur. Use of any opioid for more than 42 days within a 90 day period is considered chronic use.

chronic opioid attestation form

Opioid Attestation form Molina United healthcare Opioid Attestation form Opioid Attestation form Washington state Wellpoint opioid attestation form Opioid attestation form coordinated care Express Scripts Opioid Attestation form Anthem opioid attestation form form 13-835a

What is the 7 day opioid rule?

LIMITATIONS ON DAYS SUPPLY With specified exceptions, a physician or physician assistant shall not prescribe more than a 7-day supply of an opioid to a patient who has not had an opioid prescription in the last 12 months from that physician or physician assistant.

What should an opioid agreement include?

I agree to the following (initial each): I agree to take the medication, (name) as prescribed. If problems arise, including adverse effects, I agree to promptly notify my prescriber. I agree to obtain opioids from ONE designated licensed prescriber.