West Virginia workers' compensation claim administrators use this questionnaire for physicians prescribing opioids on a claim. It asks for the diagnosis and body part responsible for the pain, pain type, substance abuse and psychological history, unrelated conditions, a detailed pain history, prior medications and therapies with results, tapering attempts, the objective findings supporting continued opioids, consultations and random testing.
The prescribing or treating physician completes and signs the whole form, adding vendor and physician numbers and the physician's name and address.
Download the current version from the source each time; forms change without notice.
Controlled Substance 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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Question 11 asks whether you have attempted to decrease the opioid dose and, if so, when and at what intervals; if not, why not. Question 12 then asks which objective findings support the need for continued opioid therapy.
The form asks whether you discussed the risks and side effects of long-term opioid therapy with the claimant and whether you have a signed statement showing their understanding. If you have one, enclose a copy with the completed form when you return it to the claim administrator.