North Dakota > Workers Comp
Physician Request For Medication Prior Authorization SFN 54230 - North Dakota
| Physician Request For Medication Prior Authorization Form. This is a North Dakota form and can be used in Workers Comp . |
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PHYSICIAN REQUEST FOR MEDICATION PRIOR AUTHORIZATION WORKFORCE SAFETY & INSURANCE CLAIMS DIVISION SFN 54230 (01/2005) WSI HelpLine 1-800-777-5033 Questions? Call us. Report Injuries Immediately. ND Fraud and Safety Hotline 1-800-243-3331 Report Fraud and Unsafe Work Conditions. 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE NUMBER (701) 328-5984 TOLL FREE NUMBER 1-800-777-5033 TOLL FREE FAX NUMBER 1-888-786-8695 TDD NUMBER (for the hearing impaired only) (701) 328-3786 PLEASE PRINT OR TYPE USING BLACK OR BLUE INK Part 1: TO BE COMPLETED BY THE MEDICAL PROVIDER REQUESTING A MEDICATION, A MEDICATION DOSAGE, OR A MEDICATION INTERVAL THAT IS LISTED ON THE WSI EXCLUSION LIST. Injured Worker's Name Physician's Name Address Requested Drug Injured Worker's Date of Birth Physician's DEA Number City Requested Dosage Injured Worker's Claim Number (if known) Physician's Fax Number Zip Code Physician's Telephone Number State Diagnosis for this request Qualifications for coverage: Please describe reason for request and duration of need: I certify that the above prescribe medication is medically necessary for this patient's well being. In my opinion, this is reasonable and necessary in conformance with accepted standards of medical practice for the treatment of this condition. This has not been prescribed as a convenience to the patient, or solely due to the request of the patient. Physician's Signature Date Part 2: FOR WORKFORCE SAFETY & INSURANCE USE ONLY Date Received Approved - Effective dates of PA Received by From: Approved by Date To: C157 completed Entered in CMS Pharmacy Notified Physician Notified Yes Denied (Reason(s) No Yes No Yes No Yes No PLEASE FAX COMPLETED FORM TO: Workforce Safety & Insurance Fax: (701) 328-3793 Phone: (701) 328-5973 M3 American LegalNet, Inc. www.FormsWorkflow.com
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