North Dakota > Workers Comp
Independent Exercise Program Approval Request SFN 53630 - North Dakota
| Independent Exercise Program Approval Request Form. This is a North Dakota form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
INDEPENDENT EXERCISE OR WORK HARDENING / CONDITIONING PROGRAM REQUESTS CLAIMS DIVISION SFN 53630 (03/2010) 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 PRINT OR TYPE USING BLACK OR BLUE INK. TO BE COMPLETED BY THE PROVIDER REQUESTING THE PROCEDURE. PLEASE SUBMIT TO CLAIMS ADJUSTER VIA MAIL OR FAX AT LEAST 24 HOURS PRIOR TO SCHEDULED START DATE. PROVIDER INFORMATION Date Facility Address City Phone Person Requesting Review and Name of Facility State Fax Zip Code INJURED WORKER'S INFORMATION Injured Worker's Name Social Security Number Date of Birth Claim Number Date of Injury ORDERING DOCTOR INFORMATION (PLEASE PROVIDE DOCTOR APPROVAL) Ordering Physician Address City Last Date of Service with Physician State Start and End Date Phone Zip Code Dates of Prior Treatments INDEPENDENT EXERCISE PROGRAM DETAILS Cost WORK HARDENING PROGRAM DETAILS Work Hardening Is IW working? Yes No If yes, name of employer Frequency/Total Number of Visits Therapist Name Employer phone # Start and End Date of Current Request WORK CONDITIONING PROGRAM DETAILS Work Conditioning Frequency/Total Number of Visits Therapist Name Start and End Date of Current Request CURRENT STATUS / ADDITIONAL INFORMATION AUTHORIZATION Approved Denied FL or C54 Created? Adjuster Date DETAILS ON AUTHORIZATION C59a American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
