North Dakota Designated Medical ProviderSelection Form

• Category: North Dakota Workers Compensation - Official
• State: North Dakota
• Control #: ND-SKU-0346
• Format: PDF

Description

Designated Medical ProviderSelection Form North Dakota Designated Medical Provider Selection Form is a document used by North Dakota employers to designate a medical provider for workers' compensation injury claims. This form allows employers to select a medical provider from a list of providers approved by the North Dakota Workers' Compensation Division. The form contains two sections: 1. Provider Selection: This section includes a list of approved providers with their contact information. The employer must select a provider from the list and provide the provider's name, address, and contact information. 2. Authorization: This section allows the employer to authorize the selected provider to provide medical treatment and services to the injured employee. The employer must sign and date the form in order to authorize the provider. There are two types of North Dakota Designated Medical Provider Selection Forms: one for general medical services and one specifically for physical therapy services.

North Dakota Designated Medical Provider Selection Form is a document used by North Dakota employers to designate a medical provider for workers' compensation injury claims. This form allows employers to select a medical provider from a list of providers approved by the North Dakota Workers' Compensation Division. The form contains two sections: 1. Provider Selection: This section includes a list of approved providers with their contact information. The employer must select a provider from the list and provide the provider's name, address, and contact information. 2. Authorization: This section allows the employer to authorize the selected provider to provide medical treatment and services to the injured employee. The employer must sign and date the form in order to authorize the provider. There are two types of North Dakota Designated Medical Provider Selection Forms: one for general medical services and one specifically for physical therapy services.