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Complete all sections of the form. • Submit the form at least 2 weeks before coverage ends to avoid abrupt stoppage in coverage.Fax this form to: 1-866-434-5523. Phone: 1-866-434-5524. The info requested in this form, although extensive, is based on best practice standards and the CDC Chronic Pain Opioid Guidelines. This form is required when patients begin chronic use of opioid, when daily opioid doses exceed 120 MME, or when both occur. It must be legible, correct, and complete or form will be returned. Exception Request and Record of Justification (SMA-168) Form . Chronic – New requirements for ALL opioid prescriptions. To submit a request once an opioid prescription and attestation has been received: Bill the opioid prescription first.