Get the free Chronic Opioid Attestation Form SEBB - Premera Blue Cross

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Opioid Attestation Form Please FAX responses to: (800) 8697791. Phone: (855) 3224082, Options 0,1,2,3. NOTE: This version must be used effective 04/01/2020. Date of Request Patient Date of Birth Molina

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How to fill out chronic opioid attestation form

01

Obtain a copy of the chronic opioid attestation form from your healthcare provider or pharmacy.

02

Complete all required fields on the form, including personal information such as name, date of birth, and contact information.

03

Provide information about your chronic pain condition, including the duration of pain, previous treatments, and current opioid medications.

04

Review the completed form for accuracy and sign and date it to certify the information provided is true and accurate.

05

Return the form to your healthcare provider or pharmacy as instructed.

Who needs chronic opioid attestation form?

01

Individuals who are prescribed long-term opioid medications for chronic pain management may need to fill out a chronic opioid attestation form.

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What is chronic opioid attestation form?

Chronic opioid attestation form is a document that healthcare providers use to attest that they have discussed the risks of long-term opioid therapy with their patients.

Who is required to file chronic opioid attestation form?

Healthcare providers who prescribe opioids for chronic pain are required to file chronic opioid attestation form.

How to fill out chronic opioid attestation form?

To fill out chronic opioid attestation form, healthcare providers need to document the discussion about risks of long-term opioid therapy with their patients and obtain patient's signature.

What is the purpose of chronic opioid attestation form?

The purpose of chronic opioid attestation form is to ensure that patients are informed about the risks of long-term opioid therapy and that healthcare providers have discussed these risks with them.

What information must be reported on chronic opioid attestation form?

Information about the discussion on risks of long-term opioid therapy and patient's signature must be reported on chronic opioid attestation form.

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