DHS-8063-ENG 3-21 (1.0.4)

Opioid Prescribing Improvement Program (OPIP) Inquiry

Name of person completing form

FIRST NAME

LAST NAME

PREFERRED EMAIL

PREFERRED PHONE NUMBER

TITLE/CREDENTIALS

NAME OF PERSON THIS INQUIRY IS ABOUT, if different from above

PROVIDER NPI (if applicable)

TOPIC

QUESTION

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