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 ProviderSelection Form
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How to fill out North Dakota Designated Medical ProviderSelection Form?
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FAQ
A DMP is a medical professional or a facility selected by the employer to treat work related injuries. All employers in North Dakota have the option of selecting a DMP. Employers may choose a single provider, a group of providers, or any combination of provider specialties.
How do I apply for workers' compensation benefits? Applying for workers' compensation benefits can be completed in a few different ways. You can complete a First Report of Injury (FROI) online. You can also fax a completed FROI to WSI at 701-328-3820 or 888-786-8695 or mail it to PO Box 5585, Bismarck, ND 58506-5585.
Important information about benefits Wage-loss benefits are paid at a rate of 2/3s of the pre-injury gross weekly wage. The weekly benefit may not exceed the maximum benefit at the time of disability. The weekly benefit also cannot exceed the net wages after taxes.
North Dakota's Workers' Compensation law, with limited exceptions, requires all employers to insure all employees including full-time, part-time, seasonal, and occasional workers before employees begin working. It is unlawful to deduct any portion of the premium from wages or salary of any employee.
Designated Medical Provider (DMP)
Designated Medical Provider (DMP)