Generic short-acting opioids are covered without authorization for up to 6 weeks after a Washington work injury; past that point, prescribers use this form to request coverage between 6 and 12 weeks from injury or surgery. It records prior chronic opioid use, function and pain against baseline, PMP and urine drug test results, addiction, substance use and depression screening, contraindications and total MED.
The prescribing provider completes every section and signs with an L&I provider number or NPI.
Download the current version from the source each time; forms change without notice.
Subacute Opioid Request Form
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.
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.
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Both bill the Subacute Opioid Request Form. Use 1076M when screening results are documented in the medical record but not submitted. Use 1077M, which pays more, when you send copies of the urine drug test, opioid addiction risk screen, substance use disorder screen and depression screen if indicated.
When opioids are prescribed between 6 and 12 weeks after the date of injury or surgery. Generic short-acting opioids are covered without authorization for up to 6 weeks for an acute injury, and after 12 weeks the Chronic Opioid Request Form applies instead.