North Dakota > Workers Comp
Designated Medical ProviderSelection Form SFN 58225 - North Dakota
| Designated Medical ProviderSelection Form Form. This is a North Dakota form and can be used in Workers Comp . |
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DESIGNATED MEDICAL PROVIDER SELECTION CUSTOMER SERVICE DIVISION SFN 58225 (09/2010) 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Please complete a separate form for each business location. Date Employer Account Number Business / Legal Name Employer Contact Telephone Number Name and title of person providing information Business Address / City / State / Zip Has the medical provider been informed of your selection? Yes No If no, WSI will not recognize your selection. Our designated medical provider(s) for the above location are: Name Address City If you have additional designated medical providers, please attach additional pages as needed. Please Note: Designated Medical Provider (DMP) selection should be reviewed annually. The DMP selection does not apply to emergency care. Employees have the right to add additional medical providers to the above list (referred to as opting out) Employees must notify the employer of their additional medical provider or opting out prior to an injury. There can be more than one DMP. DMPs can be individuals, clinics, hospitals or any combination. They can be medical doctors, chiropractors, osteopaths, dentists, optometrists or any combination. The DMP will remain in effect until the employer notifies WSI of changes. If an employee opts out, he/she should retain a copy of the form. Employer Signature Mail completed form to WSI at: Workforce Safety & Insurance PO Box 5585 Bismarck ND 58506-5585 Date American LegalNet, Inc. www.FormsWorkFlow.com DESIGNATED MEDICAL PROVIDER SELECTION FORM The designated medical providers for Employer's Name City Provider are: I have been informed of my employer's designated medical provider provisions. Signature of Employee Employee Name (please print) Date I wish to add the following designated provider(s) to seek treatment from in the event of a workplace injury or illness: Provider's Name Provider's Address City Provider's Name City Provider's Name City State Provider's Address State Provider's Address State Zip Code Zip Code Zip Code Do not return this form to WSI. This form should be kept by the employer and a copy given to the employee for their records. DMP selection should be reviewed annually. WSI may not pay for medical treatment by another provider unless a designated provider refers you or you list the provider above. Emergency care is exempt from the designated medical provider requirement. American LegalNet, Inc. www.FormsWorkFlow.com
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