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Medical Providers Forms

  • ADA Dental
  • Advanced Beneficiary Notice of Non-Coverage (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
  • 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)
  • UB 04
  • Utilization Review Chiropractor Request (UR-Chiro)
  • Utilization Review Request (UR-C)
  • Visual Analogue Pain Scale
  • Work Hardening/Conditioning Form (C59b)

Medical Providers

  • Treating Patients
  • Authorization
  • Billing/Payment
  • Pharmacy
  • Forms
  • Resources
  • Online Services

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

 

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