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Minnesota Model Opioid Contract for Long-Term Treatment

Minnesota's workers' compensation treatment parameters require a written contract between prescriber and patient before long-term opioid treatment, and this optional DLI model meets that requirement once completed and placed in the medical record. It covers risks and side effects, treatment goals, a single prescriber for controlled drugs, refills, lost prescriptions, monitoring through the Prescription Monitoring Program and urine testing, and tapering if opioids are stopped.

Who completes it

The prescribing health care provider and the patient complete it together: both names are printed, the provider names a covering prescriber, and both sign and date.

Submitting and payment

How to submit it
Keep the signed contract in the patient's medical record, where it is available to the insurer.
Who pays
The model contract sets no fee, and providers are not required to use it to meet the rule's contract requirement.

Good to know

  • Authorized under Minnesota Rules 5221.6110, subp. 7; once completed and placed in the record, the model is deemed to meet the rule.
  • The patient agrees to get opioids and other controlled pain drugs only from this provider or a named covering provider, except for another condition or hospitalization.
  • Lost or stolen prescriptions may not be replaced and can be replaced only once; refills are given during regular office hours only and never early.
  • The contract notes the provider must give written reports of work ability when workers' compensation rules require them. Revised May 1, 2016.

Get the official form

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

Model patient/provider contract for long-term treatment with opioid medication

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.

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Frequently asked questions

Is the Minnesota model opioid contract mandatory?

No. The rule requires a contract before long-term opioid treatment, but providers and patients are not required to use this model. If they do, it is deemed to meet Minnesota Rules 5221.6110 once completed and made part of the medical record. DLI encourages discussing each agreement before signing.

What monitoring does the model opioid contract allow?

The patient agrees the provider may contact other treating providers about opioid use, will periodically check the Minnesota Prescription Monitoring Program database, and may request urine specimens to monitor compliance. The patient also agrees to abstain from all illegal drugs.

What happens if opioid treatment ends under the contract?

The provider may end opioid treatment if the patient does not comply with the contract. If medication is stopped for any reason, the provider agrees to taper it in a controlled way to avoid withdrawal and to offer alternative treatment or a referral to another provider.