Fillable Printable Form 252-097-000
Fillable Printable Form 252-097-000
Form 252-097-000
Department of Labor and Industries
PO Box 44291
Olympia WA 98504-4291
Opioids.Lni.wa.gov
SUBACUTE OPIOID REQUEST FORM
Billing code 1 076M or 107 7M
Worker’s name
Claim nu mber
Was the worker on chron i c opioids at the t ime of t he injury ?
Yes No
Opioids must result in clinically meaningful improvement in function (CMIF) and pain in the acute phase. This
means improvement of at least 30% as compared to baseline or in response to a dose change.
Function and pain assessment
Current pain interference — This scale’s exa mp les of activit ies at different lev els are not meant t o be exclusive. I n the
last month, how mu ch has pain interfer ed with the w or ker ’s daily activities and fun c t io ns ? Circle number .
0 — No interferenc e.Goes to work each day, has a social life outside of work, takes an active part in family life.
1 — Can work/volunteer, b e acti ve eight hours daily, takes part in family life, has limited outside social activities.
2 — Can work/volunteer for at least six hours daily, has energy to make plans for one evening social activity during the week,
is active on the weekends.
3 — Can work/volunteer for a few hours daily, is active at least five hours daily, does simple activities on the weekends.
4 — Can work/volunteer limited hours, has lim ited soc ial acti vities on weekends.
5 — Not able to work/volunteer, struggles with home responsi bi lities and outs ide ac tiv it ies.
6 — Does simple chores around home, has minimal outside activities two days a week.
7 — Gets dressed in the morning, has minimal activities at home, has contact with friends via phone or email.
8 — Gets out of bed but doesn’t get dressed, stays at home all day.
9 — Stays in bed at least half the day, has no contact with the outside world.
10 — Unable to carry out any a ctivities.Stays in bed all day, feels helpless and hopeless about life.
Date of first function assessment or before a dose change(baseline): Baseline function:_____________
If an alternative function scaleis used, indicate name of scale: Current function: __________________
Current pain intensity — In the last month, on average, how would you rate the worker’s pain? That is, their usual pain at
times they were in pain. Circle number.
No pain
Mild pain
Moderate pai n
Severe pain
Pain as bad as could be
0
1
2
3
4
5
6
7
8
9
10
Date of first pain assessment (baseline): Baseline pain intensity: _____________
Screening
For free, easy to use, and validated screening tools and opioid calculator, visit www.agencymeddirectors.wa.gov/opioiddosing.asp.
Have you documented in the m edical records the foll owing. . .
1.Checked the state’s prescription monitoring program and is it consistent with prescribing record and
worker’s report?
Yes
No
2. Administered a urine drug test and verified the worker has no aberrant behaviors (e.g. pres ence of
cocaine,heroin, alcohol, amphetamine/methamphetamine or non-prescribed drug; negative for
prescr ibed opioi ds ) ?
Yes
No
3. Screened the worker for risk of opioid addiction?
Yes
No
4. Screened the worker for current or former substance use disorder?
Yes
No
5. If indicated, screened the worker for depression and results indicated no severe depression?
Yes
No
6. Assessed for potential contraindications to the use of opioids?
Yes
No
7. Verified the worker has no known evidence of or is not at high risk for serious adverse outcome from
opioid use (e.g. COPD, asthma, sleep apnea, apparent intoxication)?
Yes
No
Dose
Current opioid
Dose (MED mg/d)
Current opioid
Dose (MED mg/d)
Total ME D
Sign
Provider name
L&I provider number/ NPI
Phone number
Provider signat ure
Date
F252-097-000 Subacute Opioid Request Form01-2015INDEX: OPI
RESET
Instructions for using the Subacute Opioid Request Form
Providers who treat injured workers are expected to follow the best practices outlined in the following:
•Pain management rules from the W ashington State Department of Health.
•Interagency Guideline on Opioid Dosing for Chronic Non-Cancer Pain, Agency Medical Directors’ Group,
2010.
•Prescribing Opioids to Treat Pain in Injured Workers, Labor and Industries, 2013.
How to use t his form
•Use this form to request coverage for opioids between 6 weeks and12 weeks from the date of injury or
surgery.
•Complete allsections of the form.
•Submit the form at least 2 weeks before coverage ends to avoid abrupt stoppage in coverage.
•Send chart notes and reports as required.
•Make sure information is legible.
How to bill
•Use billing code 1076M if this form is submitted, but results of screenings are documented in the medical
record.
•Use billing code 1077M for increased reimbur sement if copies of all required screenings are submitted along
with this form:
oUrine drug test.
oScreening for risk of opioid addiction.
oScreening for current or former substance use disorder.
oScreening for depression, if indicated.
How to submit your request
State Fund
Mail: Departmentof Labor and Industries
PO Box 44291
Olympia WA 98504-4291
FAX:Choose any number
360-902-4292360-902-4565360-902-4566360-902-4567
360-902-5230360-902-6100360-902-6252360-902-6460
Self-Insurance
Contact the self-insurer or their third-party administrator.
For a list of self-insured businesses: www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp
F252-097-000 Subacute Opioid Request Form01-2015INDEX: OPI
