Washington State Department of Social and Health Services Home page

Forms

These medications must be prescribed by a physician in conjunction with state certified chemical dependency treatment and require a completed authorization form for Medicaid payment. 

  1. Suboxone Prior Authorization Form (DSHS 13-720) WordPDF

Suboxone is used in the treatment of opioid dependence.  It is a combination medication of buprenorphine and naloxone which was developed to reduce the diversion potential.  This medication can be prescribed from a physician’s who has obtained a DATA 2000 waiver by the Drug Enforcement Administration and SAMHSA.  The patient must be in chemical dependency treatment prior to the approval and for the duration of the medication authorization.

  1. Suboxone Exemption Request - Prior Authorization Form (DSHS 13-750)  Word, PDF

The exemption requires the patient to have remained in chemical dependency treatment, has made progress in treatment, and has not taken any other opiate medications during the prior six month authorization. The other opiate medication verification is obtained through Medicaid pharmacy records and a six month medication profile from all the patient’s pharmacies.  If the patient has left chemical dependency treatment or has used opiate medication(s) during the prior six months, the exemption may be denied. If the prescribing physician is aware of a unique situation where the patient need opiate medication during the authorization period, the physician should document this information and fax it to DBHR along with the exemption request.  No authorization will be approved beyond the exemption period.

 

     3. Buprenorphine for Pregnancy - Prior Authorization Form (DSHS 13-901)  Word, PDF (New)  

The generic buprenorphine may be prescribed during pregnancy for an opiate addicted pregnant patient.  The DATA 2000 waivered prescribing physician must:

  • Be in on-going consultation with an expert in opiate addiction and high-risk pregnancy,
  • Provide the confirmed estimated due date of the patient, and
  • Provide the name of the prenatal medical provider.

 

The patient must be in chemical dependency treatment for the duration of the medication authorization period.  The medication must be prescribed in 7 day increments and urine drug screen must be obtained prior to the next prescription being released.  The patient can remain on the medication for the duration of their pregnancy.  Once the patient has delivered, the patient must change to Suboxone.

  1. Vivitrol IM Physician - Prior Authorization Form (DSHS 13-791)  Word, PDF  (New)

Vivitrol IM is approved for both alcohol and opiate dependency.  Medicaid will reimburse for this medication under certain criteria which is attached to the prior authorization form. The patient must be enrolled in chemical dependency treatment for the full duration of the medication.  This medication may only be administered in a physician’s office and is limited to six doses in 24 weeks.

  1. Campral Prior Authorization Form (DSHS 13-749)  Word, PDF

 

    6.  Naltrexone Prior Authorization Form (DSHS 13-677) Word, PDF

 

The patient must be enrolled in chemical dependency treatment for both Campral and Naltrexone.  The medication is limited to one year for Campral and 12 weeks for Naltrexone. 

 

Shortcut to Adjunctive Medications webpage (info re opiate treatment and alcoholism)

  • Fee Declaration Form (Word fill-in Form )  Certified agencies complete this form yearly when they pay their annual certification fee.  The new certificate of approval is mailed once DBHR receives the fee, if any, with the Fee Declaration Form.  Agencies with a zero-due reduced or exempt fee still need to fill out the form and send it back to DBHR Certification Section.  Your new certificate will be sent once DBHR receives the Certification Fee Declaration Form.)
  • Stakeholder Notice: Increased Certification Fees
  • Privacy Notice
Relocation Approval Request Form

Sample Floor Plan

Accessibility Barrier Checklist  

  • Certified Provider Branch Agency Certification

Branch Application Form    Application Instructions

Sample Floor Plan

Accessibility Barrier Checklist

  • Certified Provider Added Service Certification
Added Services Application form

Sample Floor Plan

Accessibility Barrier Checklist

  • Change of Ownership Application (CHOW)
CHOW Application Form

CHOW Instructions  

  • Criminal Background Check form (from Washington State Patrol) [PDF Fill-In]   
  • Voluntary Certification Suspension/Cancellation Request Form for an agency, branch, or service ( Word ) ( PDF  )
  • Sample Approved Supervisor -- Documentation of Qualifications for CDP Trainee [PDF] or [Word]
  • Sample CDP Trainee Training Plan Documentation form [PDF] or [Word]
  • Counseling Staff Worksheet (includes total face-to-face patient hours for each of the last three months and number of patients assigned to each counselor) [PDF] or [Word]

These forms are used in addition to the application process for DBHR Certification and/or Accreditation as an Opiate Treatment Program Provider (OTP) in Washington State.

  • OTP Application Addendum [PDF] or [Word] (fill-in form)
  • Community Relations Plan [PDF] or [Word] (fill-in form)
  • Community Relations Plan Attachment List [PDF] or [Word]
  • DBHR Certification Procedure No. CS-21, OTP Certification/Accreditation Applications [PDF] or [Word]
  • Important Web Links for OTP Applicants [PDF] or [Word]
  • OTP Critical Event Reporting Form  [Word] (fill-in form)
    OTPs must use this form when reporting a critical event per WAC 388-805-150(12)(c) patient death in an OTP and WAC 388-805-005 Critical Event (8) An error in program administered medication requiring urgent medical intervention.

Request for Records, DSHS 17-041 (To request DBHR records, including records about a DBHR contracted or certified agency.)

Authorization DSHS 17-063 Request for Patient Records (Purpose: Use this form to request the release of your confidential patient/client information held by DSHS to another party.)

See Forms on the TARGET webpage