Medical Providers Forms

ADA Dental
Advanced Beneficiary Notice (ABN)
Capability Assessment Form (C3)
Chiropratic Progress/Final Report (C25)
CMS 1500
Dallas Pain Questionnaire
Dentist Report of Injury (C31)
Electro Medical Device Request (M5)
First Report of Injury
Fraud Report Form
Independent Exercise Form (C59a)
Medical Bill Appeal (M6)
Medical Service Dispute Resolution Request (M2)
Neck Disability Index
Oswestry Questionnaire
Pain Questionnaire
Payee Registration and Substitute W-9
Physician's Request for Medication Prior Authorization (M11)
Post Injection Pain Response
Ransford Pain Drawing
Relistor Prior Authorization Request (M12)
Surgery Expectation Questionnaire
UB 04
Utilization Review Chiropractor Request (UR-Chiro)
Utilization Review Request (UR-C)
Visual Analogue Pain Scale
Work Hardening/Conditioning Form (C59b)

About Us

North Dakota Workforce Safety & Insurance is the sole provider and administrator of the workers’ compensation system in North Dakota.

Reports

Careers

Are you looking for a career where you can provide the best services and solutions to injured workers, employers, and medical facilities? Join our team today.

Fraud Awareness

North Dakota Workforce Safety & Insurance has a responsibility to the employers and employees of North Dakota to investigate all allegations of fraud.

Contact Us

Phone:	800-777-5033
Email:	ndwsi@nd.gov
Address:	1600 E. Century Ave, Ste 1 Bismarck, ND 58503