Washington prescribers and injured workers sign this two-page agreement when chronic opioid therapy is part of treatment on a workers' compensation claim. The worker agrees to take medications as prescribed, use one prescriber and pharmacy where possible, take part in return-to-work efforts, allow random drug tests and pill counts, and keep appointments. It also lists when the provider will stop or change opioid treatment.
The worker reads and signs it, naming the prescriber and pharmacy, and the prescribing provider signs as well. Both acknowledge both sides of the agreement.
Download the current version from the source each time; forms change without notice.
Opioid Treatment Agreement
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Yearly. The form tells providers to renew it every year, and the Chronic Opioid Request Form asks whether a treatment agreement was signed and notes it should be renewed yearly. A new agreement is also expected when a new prescriber takes over the worker's chronic opioid therapy.
Yes. L&I publishes a Spanish version as F252-095-999. Whichever language is used, the worker signs after reading both sides, the provider signs, a copy goes to the worker and another to L&I, and the signed original stays in the chart.