Controlled Substances Form

BI-233 01/06 Controlled Substance Follow-Up Report Claimant Name: Claim Number: Claimant SSN: Date of Injury: Physician's Name and Address: Date: Vendor Number: Physician's Phone Number: Return completed form to: BrickStreet Mutual Insurance P.O.Box 3151 Charleston, West Virginia 25332-3151 1. Date of this exam: 2. What diagnosis is responsible for the claimant's pain? 3. Body part involved: 4. Is the claimant's pain: Acute Chronic Intractable Psychogenic Dosage Neurogenic Frequency 5. Please indicate all controlled substances that this claimant is receiving: Drug Name 6. Please indicate if there have been any changes or reductions in opioids within the last 30 days. 7. Is the claimant receiving controlled substances from any other physicians? Drug: Drug: Drug: Yes No Physician: Physician: Physician: If yes, please list drugs and prescribing physician. 8. Please indicate key objective findings upon which you base your decision to continue prescribing controlled substances. 9. In your opinion, what is the estimated length of time thi s claimant will require the use of the currently prescribed controlled substances? I certify the statements and answers set forth in this section are true and correct to the best of my knowledge. I am aware the law, specifically § 61 -3-24g, provides for severe penalties if I knowingly certify a false report or statement, withhold material fact or statement or knowingly aid or abet anyone attempting to secure benefits to which he or she is not entitled. In signing this form, I acknowledge my contractual obligations to BrickStreet Insurance and agree to release any office notes and test results immediately to BrickStreet Insurance. Physician Signature: Date: / / BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.USCourtForms.com