Follow the steps to complete the worksheet efficiently.

1. Click ‘Get Form’ button to obtain the worksheet and open it in your online editor.
2. Begin by answering the initial question regarding whether the request is for medication prescribed for pain related to cancer, palliative care, or end-of-life care. Indicate 'Yes' or 'No.' If 'Yes,' you do not need to complete this form.
3. In the Recipient Name section, fill in the full name of the person for whom the treatment is intended.
4. Enter the Policy ID number of the recipient in the specified field.
5. Provide the date of birth (DOB) for the recipient.
6. Include the name and address of the EPSDT Support Coordinator, if applicable.
7. Fill out the prescriber details, including the name, specialty, and Medicaid Provider ID or NPI number.
8. Document any medication allergies that the recipient has.
9. Provide the call-back phone number, office fax number, and office contact name.
10. Input recipient's weight in kilograms and height in feet and inches.
11. Select the type of request (quantity limit override for opioid analgesic) and specify the information about the requested drug, including name, dosage form, strength, directions, and quantity requested.
12. Complete the Treatment Information section by clarifying if the medication is for an acute or chronic condition, along with any relevant additional details.
13. Fill in the diagnoses for which the opioid is prescribed, including the ICD code and description.
14. Document other treatments (both pharmacological and non-pharmacological) that were tried previously, along with reasons for discontinuation if applicable.
15. In the Prescriber Attestation section, answer 'Yes' or 'No' to the various statements provided, ensuring reasons are explained for all 'No' responses.
16. Finalize by ensuring all required signatures and dates are provided. Save changes, download, print, or share the completed form as needed.

Complete the Amerigroup Opioid Analgesic Treatment Worksheet online today for effective pain management.