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 Evening
7:23:51 PM CDT
Thursday, April 17, 2014

spacer image
Medical Providers Section Header Medical Providers Logo

Treating an Injured Worker

Topics ICD-9 Forms & Publications Medical Provider's Guide
Treating An Injured Worker Treatment Guidelines First Report of Injury (FROI) Form  
Claim Information Claim Number Lookup Capability Assessment form (C3)  
Medical Treatment Medical Provider Appeal Process Medical Services Dispute Resolution Request (M2)  
Subsequent Treatment   Provider Request for Adjustment (M6) form  

Subsequent Treatment
For subsequent medical treatment the Capability Assessment form (C3) form must be completed. This information will assist employers in determining appropriate accommodations. Keeping a worker on the job in transitional duty reduces the worker’s likelihood of long-term disability. Please return the original 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 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. All medical documentation, including the C3 forms, should continue to be faxed to 1-888-786-8695 or 1-701-328-3820. Providers may call WSI Customer Service at 1-800-777-5033 to obtain a supply of the C3 forms. The C3 form cannot be used to file a claim.

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