nd.gov - The Official Portal for North Dakota State Government
North Dakota: Legendary. Follow the trail of legends
Workforce Safety & Insurance Logo Top of the page place holder

   
Contact Us       About Us       News       Careers       Calendar       Free e-Newsletter       RFI/RFP       Links       Site Map      
spacer image
gray hexagon imagespacer imageForms/Library 
red hexagon imagespacer imageEmployers 
orange hexagon imagespacer imageWorkers 
yellow hexagon imagespacer imageMedical Providers green hexagon imagespacer imageSafety & Loss Control 
purple hexagon imagespacer imageOnline Services 
tan hexagon imagespacer imageFraud Awareness 
spacer imageHOME 


Good Morning
2:39:12 AM CDT
Wednesday, April 16, 2014

spacer image
Medical Providers Section Header Medical Providers Logo

Chiropractic Services

Topics Palliative Care Requirements Forms & Publications Provider Request for Adjustment (M6) form
General Information Documentation Requirements First Report of Injury (FROI) Form Chiropractic Progress/Final Report (C25)
Chiropractic Treatment Window Subsequent Treatment Capability Assessment form (C3) Utilization Review Chiropractic Request (UR-Chiro)
Authorization Process   Medical Services Dispute Resolution Request (M2)  

Subsequent Treatment

For continued medical treatment, the Capability Assessment form (C3) form needs to be completed to address any limited capabilities. This information assists the employers in determining appropriate accommodations.

Please return the original C3 form to WSI, provide a copy for the injured worker to give to their employer, and retain a copy for your records. Completion of the C3 form is not a substitute for chart notes. Notes (e.g., SOAP format) are needed for continued management of the claim as well as for payment of services. Additionally, the form cannot be used to file a claim.

When treatment has been completed and the patient has reached maximum medical improvement, the Chiropractic Progress/Final Report (C25) should be completed.

spacer image

Back to Top 

Employers | Workers | Medical Providers | Safety | Online Services | Fraud Awareness | Forms/Library 
Home | Contact Us | About Us | News | Careers | Calendar | Free e-Newsletter | Links | Site Map

2013 Workforce Safety & Insurance | comments: wsiwebmaster@nd.gov
 

Section 508 Accessibility Link    CSS Validation Link