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Opioid Progress Report Supplement Chronic Noncancer Pain F245-359-000 - Washington

Opioid Progress Report Supplement Chronic Noncancer Pain Form. This is a Washington form and can be used in Claims Workers Comp .
 Fillable pdf Last Modified 10/21/2011
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Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 OPIOID PROGRESS REPORT CHRONIC, NON-CANCER PAIN Billing code 1057M Provider information on back Worker's Name Worker's Signature 0123 Today's Date (circle number) Claim Number 8 9 10 1. On average, how bad was your pain last week? 0= no pain 10= worst possible pain 4 5 6 7 WORKER 2. What activities are most difficult because of pain? Activities may include sitting, standing, walking, reaching overhead, climbing stairs, etc. Pick 2 activities and mark the changes from your last doctor visit. Please use the same activities each time you complete this form. Activity 1: Activity 2: ________________________________ ________________________________ (check all that apply) I can do: I can do: more more less less no change no change PROGRESS REPORT (circle number) Estimate worker's function on opioids 0= severe impact on function 0123 4 5 6 7 8 9 10 10= returned to level of function prior to injury Worker has a signed opioid agreement within past 6 months Last date of agreement.______________________ (If new agreement, please submit copy) PROVIDER Is there concern about opioid use? Misuse Tolerance Yes No If yes, check all that apply Toxicity/side effects Dependence Have you requested a random drug test? If so, please submit a copy Random drug screening is recommended and does not require pre-authorization RECOMMENDATION/TREATMENT PLAN (check all that apply) Worker has reached maximum medical improvement (MMI) I will continue to prescribe opioids and monitor I have started to wean worker from opioids and will finish by _________________________ I referred for pain management consultation to Dr. ______________ Date: _____________ I need additional resources to assist me in managing this worker's pain. Please specify: Other (please explain) SIGN Signature: Print Name: Doctor ARNP PA-C Phone Number: Provider or NPI Number : Date: F245-359-000 opioid progress report chronic non-cancer pain 12-2010 Index: MED American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR OPIOID PROGRESS REPORT CHRONIC, NON-CANCER PAIN BILLING TIPS: · Complete relevant sections of the form. · Send chart notes and reports as required. · Make sure information is legible. · Use billing code 1057M. DOCUMENTATION TIPS: · To measure function, ask the worker to describe the same activities at each visit. · To estimate the worker's level of function consider all relevant data including: information that is self-reported ­ worker's response to activities, and information from another observer such as a consulting physician or a physical capacities examination by a physical therapist. · Document any changes in the level of function and pain. When prescribing opioids for chronic, non-cancer pain, the attending physician must submit this form, or an equivalent form giving the same information, at least every 60 days. · Providers are encouraged to submit this form after each visit. · A signed opioid agreement must be submitted every 6 months. · L&I will not pay for opioids once the worker has reached maximum medical improvement for the accepted condition. PAYMENT FOR OPIOID MEDICATIONS MAY BE DENIED FOR: · Missing or inadequate documentation. · Noncompliance with the treatment plan. · No substantial improvement in pain and functional status after three months of opioid treatment. · Evidence of misuse of opioids or other drugs, or noncompliance with the attending provider's request for a drug screen. If you need more information: On-Line: Call: www.lni.wa.gov and search for opioids. WAC 296-20-03019 through WAC 296-20-03024. www.agencymeddirectors.wa.gov for helpful resources to manage chronic non-cancer pain Provider Hotline: 1-800-848-0811 Send reports to: State Fund: Dept of Labor and Industries ­ Claim Section PO Box 44291, Olympia WA 98504-4291 FAX: Choose any number: 360-902-4292 360-902-5230 360-902-4565 360-902-6100 360-902-4566 360-902-6252 360-902-4567 360-902-6460 Self-Insurance: Contact the Self-Insured Employer/Third Party Administrator. On-Line: www.lni.wa.gov/download/Selfins/Rpt4097d.txt F245-359-000 opioid progress report chronic non-cancer pain 12-2010 Index: MED American LegalNet, Inc. www.FormsWorkFlow.com Department of Labor and Industries PO Box 44291 Olympia WA 98504-4291 OPIOID TREATMENT AGREEMENT Claim No. Patient Name: Opioid (narcotic) treatment for chronic pain is used to reduce pain and improve what you are able to do each day. Along with opioid treatment, other medical care may be prescribed to help improve your ability to do daily activities. This may include exercise, use of non-narcotic analgesics, physical therapy, psychological counseling or other therapies or treatment. Vocational counseling may be provided to assist in your return to work effort. I, _______________________________, understand that compliance with the following guidelines is important in continuing pain treatment with Dr. _____________________. 1. I understand that I have the following responsibilities: a. I will take medications only at the dose and frequency prescribed. b. I will not increase or change medications without the approval of this provider. c. I will actively participate in Return to Work (RTW) efforts and in any program designed to improve function (including social, physical, psychological and daily or work activities). d. I will not request opioids or any other pain medicine from providers other than from this one. This provider will approve or prescribe all other mind and mood altering drugs. e. I will inform this provider of all other medications that I am taking. f. I will obtain all medications from one pharmacy, when possible. By signing this agreement, I give consent to this provider to talk with the pharmacist. g. I will protect my prescriptions and medications. Only one lost prescription or medication will be replaced in a single calendar year. I will keep all medications from children. h. I agree to participate in psychiatric or psychological assessments, if necessary. i. If I have an addiction problem, I will not use illegal or street drugs or alcohol. This provider may ask me to follow through with a program to address this issue. Such programs may include the following: 12-step program and securing a sponsor Individual counseling Inpatient or outpatient treatment Other: __________________ 2. I understand that in the event of an emergency, this provider should be contacted and the problem will be discussed with the emergen
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