Opioid Prescribing Improvement Program (OPIP) Provider Confirmation

All providers required to participate in the Minnesota Department of Human Services OPIP quality improvement program must complete this form by May 15, 2022. After we receive the form, OPIP staff will provide next steps for quality improvement that are specific to you and your practice.

Provider demographics and practice locations

NAME

PRIMARY PLACE OF EMPLOYMENT

SECONDARY PLACE OF EMPLOYMENT (IF APPLICABLE)

PREFERRED EMAIL ADDRESS

PREFERRED PHONE NUMBER

DESCRIBE YOUR SPECIALTY AND ANY PRACTICE NUANCES: (FOR EXAMPLE, RURAL, SOLO, PAIN, SKILLED NURSING FACILITY , SURGICAL, PALLIATIVE, EMERGENCY DEPARTMENT COVERAGE, OR SIMILAR)

WILL YOU REQUIRE PRESCRIPTION DATA AT THE INDIVIDUAL PATIENT LEVEL TO UNDERSTAND YOUR DHS PRESCRIBING REPORT AND QI REQUIREMENTS?

YES