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Washington F252-091-000: Chronic Opioid Request Form

Washington prescribers use this form to request workers' compensation coverage of opioids beyond 12 weeks from injury or surgery, and every 90 days during chronic opioid therapy. It documents pain interference on a 0-10 function scale against baseline, screening steps such as urine drug tests and prescription monitoring checks, a signed treatment agreement, and current opioids with the total morphine equivalent dose.

Who completes it

The prescribing provider completes all sections and signs with an L&I provider number or NPI.

Submitting and payment

How to submit it
For State Fund claims, mail or fax it to L&I as listed on the form at least 2 weeks before coverage ends, with chart notes and reports. For self-insured claims, contact the self-insurer or its third-party administrator.
Who pays
Bill completion of the form with local code 1078M, which is printed on the form and listed in L&I's Reports and Forms payment policy.

Good to know

  • Coverage requires clinically meaningful improvement in function, at least 30% compared with baseline or after a dose change, sustained through the chronic phase.
  • A pain management consult is expected when the dose exceeds 120 mg/day MED; if the consult is exempted, explain why in the medical record.
  • Monitoring depends on risk: urine drug tests and PMP checks once a year at low risk, twice at moderate risk, and four times at high risk or above 120 mg/day MED.
  • L&I's pharmacy policy limits chronic opioid prescriptions to a maximum 28-day supply.

Get the official form

Download the current version from the source each time; forms change without notice.

Chronic Opioid Request Form

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it 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.

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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 and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

When do I submit Washington's Chronic Opioid Request Form?

When opioids continue beyond 12 weeks from the date of injury or surgery, and then every 90 days during chronic opioid therapy. Submit it at least 2 weeks before coverage ends to avoid a stoppage, and send the required chart notes and reports with it.

Does the chronic opioid request need a treatment agreement?

Yes. The form asks whether you signed a treatment agreement for chronic opioid therapy with the worker and says it should be renewed yearly. L&I's own Opioid Treatment Agreement (F252-095-000) covers this, and a copy goes to L&I.