Prescriber's request for an exemption from WCB's mandatory generic drug policy.
- Completed by
- Prescriber
- Issued by
- WCB Nova Scotia
- Format
- Fillable PDF
- Language
- English
WCB Nova Scotia Substance Abuse Assessment Form
WCB Nova Scotia requires this two-page assessment before Medavie Blue Cross will process any opioid special authorization request for a worker. The prescriber records the worker's answer on whether drugs or alcohol have caused problems, scores the Opioid Risk Tool, and for moderate or high risk outlines safeguards against misuse, abuse or diversion, such as shorter dispensing intervals, witnessed dosing or surprise pill counts.
Who completes it
The prescriber completes the form with the worker and signs it with their licence number. The Opioid Risk Tool worksheet on page 2 is scored in the office, and only the total goes on page 1.
Submitting and payment
- How to submit it
- Fax or mail page 1 to Medavie Blue Cross with the first opioid special authorization request; do not fax or email the page 2 worksheet.
- Who pays
- Physicians bill fee code WCB25 through MSI for the completed form, and other prescribers invoice WCB directly.
Good to know
- Opioid Risk Tool categories printed on the form are low risk 0 to 3, moderate 4 to 7, and high risk 8 and above.
- Tool items include family and personal history of alcohol, illegal drug or prescription drug abuse, age 16 to 45, preadolescent sexual abuse and psychological disease, with different scores for women and men.
- Later opioid requests need only the opioid form, which has space to add updated substance abuse risk information if anything has changed.
- WCB also asks for an opioid treatment agreement with the patient, which must be acknowledged on the opioid form before any request is processed.
Get the official form
Download the current version from the source each time; forms change without notice.
Substance Abuse Assessment Form
Fill it with Vero
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Frequently asked questions
When is the WCB Nova Scotia Substance Abuse Assessment Form required?
It must be submitted with the patient's first opioid special authorization request, and a completed copy must be on file at Medavie Blue Cross before that request will be processed. Subsequent opioid requests need only the Pain Medication (Opioid) Special Authorization Request Form, with any updated risk information.
Should I fax the Opioid Risk Tool worksheet to WCB?
No. Page 2 is marked as a worksheet for office use only, not to be faxed or emailed. Score the tool there, then transfer the total score to page 1, which records the risk category and, for moderate or high risk, your plan to guard against misuse, abuse or diversion.
What fee code applies to the Substance Abuse Assessment Form?
Fee code WCB25, printed on the form and listed in WCB's special authorization billing information, billed through MSI with WCB responsibility. The fee covers completing and submitting the form only, so office visits are billed separately. Other prescribers, such as nurse practitioners or dentists, invoice WCB directly.