North Dakota > Workers Comp
Electro Medical Device Certification Request SFN 54391 - North Dakota
| Electro Medical Device Certification Request Form. This is a North Dakota form and can be used in Workers Comp . |
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ELECTRO MEDICAL DEVICE CERTIFICATION REQUEST MEDICAL SERVICES DIVISION SFN 54391 (04/2010) 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 Date Injured Worker Information Injured Worker's Name Date of Birth Address City State Zip Code Phone Number Claim Number Date of Injury Physician Information Ordering Physician Address City State Zip Code Phone Number Last Date of Service Therapist Information Therapist's Name Address City State Zip Code Phone Number Facility TENS Unit New Rx Yes Name City Muscle Stimulator Combination Unit (i.e.: All Stim) Other No Updated Rx for Continued Use Yes No Address State Zip Code Shipping Instructions Ship to: COMMENTS: PLEASE ATTACH THE CURRENT PRESCRIPTION M5 American LegalNet, Inc. www.FormsWorkFlow.com
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