Get Opioid Attestation Form

Filling out the Opioid Attestation Form accurately is essential for initiating prior authorization for extended opioid therapy. This guide provides clear, step-by-step instructions to assist you in completing the form effectively.

Follow the steps to complete the Opioid Attestation Form online

1. Click ‘Get Form’ button to obtain the Opioid Attestation Form and open it in your preferred online format.
2. Enter the patient's details, including their name and date of birth, to identify the individual for whom the attestation is being completed.
3. Fill in the pharmacy name and National Provider Identifier (NPI) if known, along with the pharmacy’s telephone and fax numbers for communication purposes.
4. Provide the prescriber's information, including their NPI and contact numbers for verification and correspondence.
5. Specify the medication being prescribed, including its strength, to clearly indicate the treatment being requested.
6. Include the ProviderOne ID to streamline processing with Washington Apple Health.
7. Detail the directions for use if known, outlining how the medication should be administered.
8. Indicate whether all the criteria for chronic opioid use have been met by selecting 'Yes' or 'No'. Ensure that any exceptions are documented in the patient’s chart.
9. Confirm that the requested treatment is necessary and appropriate by responding 'Yes' or 'No' as applicable.
10. Specify how long the attestation form should remain valid by entering an end date. If left blank, it will expire in 12 months.
11. Complete the form by signing and dating it, ensuring the prescriber’s specialty is also indicated.
12. Upon completion, save changes, and choose to download, print, or share the form for submission.

Complete your Opioid Attestation Form online today to ensure proper authorization for treatment.