ADVANCE BENEFICIARY NOTICE OF NON - COVERAGE MEDICAL SERVICES DIVISION SFN 59582 (0 8 /201 7 ) 1600 E Century A ve , S te 1 PO Box 5585 B ismarck ND 58506 - 5585 Telephone 800 - 777 - 5033 Toll Free Fax 888 - 786 - 8695 TTY (hearing impaired) 800 - 366 - 6888 Fraud and Safety Hotline 800 - 243 - 3331 www.workforcesafety.com SECTION 1 Claim number (First name) (Last name) Date of service Provider SECTION 2 Provider responsibility As the provider it is your responsibility to: S elect the recommen ded medical service and provide the estimated cost Review this form with the injured worker pr ior to providing the service and obtain their signature Submit completed form to Workforce Safety & Insurance (WSI) if the injured worker received the service Service Reason Estimated cost Massage Therapy May not be a covered service Acupuncture (Maximum of 18 treatments per claim) May not be a covered service Chiropractic Maintenance Care (Palliative care) May not be a covered service Nutritional Supplements May not be a covered service Trigger Point Injections (Maximum of 20 injections per claim) May not be a covered service Vertebral Axial Decompression Therapy Not a covered service Lower Level Laser Therapy Not a covered service Exercise Equipment Not a covered service Hot/cold packs or Biofreeze Not a covered service Other May not be a covered service SECTION 3 As the injured worker it is your responsibility to: Review the selected service to make an informed decision about your medical care Ask the provider questions you may have reg arding the recommended service Indicate your decision by choosing an option below and signing the form Options: check only one box Option 1. I want the selected service listed above. If WSI or my private insurance does not pay for the service, I am responsible for payment Payment may be required at the time of service and WSI is to be billed for service If WSI does pay, the medical provider will refund payments I have made Option 2 . recommended by the medical provider. SECTION 4 Signature Signing be low means you have reviewed and understand this notice. Date American LegalNet, Inc. www.FormsWorkFlow.com