Evidence status: PRACTICE FORM CURRENTLY HOSTED IN A WASHINGTON PROVIDER DOCUMENT LIBRARY / FORM REVISED JULY 2016. A two-page Long Term Pain Agreement bearing the Community Health Center of Snohomish County logo remains publicly hosted in Providence’s Washington document library. The form is marked MED Form 313A, Rev 07/16.
Selected terms
- No alcohol, marijuana, or illegal drugs while using opioids.
- No listed benzodiazepines while using opioids.
- No early refills, including for lost or stolen medication.
- One pharmacy and specific refill-calling hours.
- Outside opioid prescribing requires permission, with emergency-room use reported within 48 hours.
- Appointments must be kept or cancelled at least 24 hours in advance.
- Behavioral-health and substance-use screening may trigger mandatory referral and treatment.
- Random drug screens and pill counts may be requested; the form states a 24-hour arrival requirement and a one-hour specimen window.
- The agreement is reviewed after 12 months.
Washington law versus form terms
Many subjects overlap with Washington’s mandatory agreement framework, including testing, dose adherence, refill protocols, single pharmacy, substance restrictions, and secure medication handling. The form’s exact cannabis rule, benzodiazepine prohibition, testing deadlines, appointment rules, referral requirements, and annual review language are not automatically universal statewide terms.
Source-status warning
The form remains publicly hosted, but its own revision date is 2016. This record therefore preserves both facts rather than presenting the form as newly revised in 2026.
Sources
← Washington Contract-for-Care Evidence Library
Reviewed: October 4, 2026.