mdhhs-5793, NONOPIOID DIRECTIVE

Michigan Department of Health and Human Services

Required by MCL 333.9145 effective 3/28/2019

(Revised 6-22)

section 1 - MUST BE INCLUDED IN THE PATIENT’S MEDICAL RECORD – Do not return form to your insurer. Submit form to a health professional who must include it in the patient's medical record.

Patient Name	Date of Birth
Other Names Used by Patient	Preferred Language of Patient
Emergency Contact	Name of Primary Care Provider

Drug Allergies

section 2

The patient above must not be administered an opioid or offered a prescription for an opioid while this directive is in effect. An individual who has executed a nonopioid directive on their own behalf may revoke the directive at any time and in any way, they are able to communicate their intent to revoke the form. A guardian or patient’s advocate can revoke at any time by issuing a revocation in writing and providing notice of the revocation to the individual’s health professional or their delegate. This directive does not apply to: A patient receiving opioids for substance use disorder treatment. A patient who is in hospice. A patient is being treated at a hospital, or in a setting outside of a hospital in the case of an emergency, and, in the prescriber’s professional opinion, the administration of the opioid is medically necessary to treat the individual.

section 3 - signatures

Signature of patient, or if the patient is a minor, parent	Date
Printed name of Patient	Date
Signature of guardian or patient’s advocate, if applicable	Date
Printed name of parent/guardian/patient’s advocate, if applicable	Date

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.