C31 OF INJURY CLAIMS DIVISION SFN 53449 ( 12 /201 6 ) 1600 E C entury A ve , S te 1 PO Box 5585 Bismarck 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. w orkforce s afety.com SECTION 1 General information - completion of this section is required Claim number (First name) (Last name) Social Security number* Date of birth (Street address, PO Box number) City State ZIP Code Date of injury SECTION 2 Dental assessment Date of visit Body part(s) /tooth number(s) Please indicate injured teeth below Diagnosis code/ICD - 10 code (s) CDT code (s) Purpose of visit Initial evaluation Re - check Discharge Does mechanism of injury coincide with finding ? Yes No If no, please explain Prior to this injury, did the worker have any problems, injuries, or treatment to the injured body part (s) ? Yes No If yes, please explain SECTION 3 restrictions ordered are in effect for home and/or work activity Injured worker is released to work with No restrictio ns T he following restrictions Restrictions are in effect until (date) Date worker may return to work Has the injured worker reached m aximum m edical i mprovement ? Yes No Date If yes, is it likely that the p ermanent p artial i mpairment will be greater than 14% whole body? Yes No Unknown SECTION 4 Follow - up plan Date of next visit with this provider C onsult/referral (List provider) Prognosis and anticipated length of dental treatment Medications prescribed Other instructions, l imitations , or future dental work SECTION 5 Release of information/fraud warning/signature By signing this form I acknowledge that I have read the fraud warning and release of information on the reverse side of this form . I understand that falsifying this claim or making a false statement regarding this claim may be a felony, punishable by substan tial fines and imprisonment. I authorize the release of information and agree that statements in this form are true and accurate. Dentist Facility Telephone number Date signed * In compliance with the Federal Privacy Act of 1974, disclosure of the Social Security number on this form is mandatory pursuant to N.D.C.C. 247 65-05-02. The Social Security number is used for identification and verification purposes. Failure to provide this information may result in a delay in processing your request. American LegalNet, Inc. www.FormsWorkFlow.com Release of information I understand and agree that North Dakota law determines all my rights an d obligations to and from WSI. I authorize any medical provider y agency, any government benefit agency including the Social Security Administration, and any edu cational agency or institution to release to WSI, its agents and attorneys, any and all information or records, including all prior records as well as those pertaining to mental h ealth, alcohol, or drug abuse, and HIV/AIDS/AIDS - related illness. I authorize healthcare providers to respond to WSI regarding my injury, including request for conclusions and opinions not otherwise contained within existing medical records. In addition, I authorize any education agency or institution to release to WSI any and all ined by 20 U.S.S 21 Sec. 1232g. This authorization continues while I have any claim open or pending before WSI. WSI is exempt from HIPAA regulations. I authorize WSI to release any information or records about my claim to third parties or their insurers for the purpose of resolving claims against third parties. I authorize the release of any medical information related to my claim to my employer. Fraud warning Any person claiming benefits or compensation from WSI who files a false claim, or makes a false statement, or fails to notify WSI as to the tion benefits will forfeit any future benefits and may be guilty of a felony which is punishable by imprisonment, substantial fines, or both. These criminal penalties are applicable to all persons dealing with WSI, including injured workers, employers, medical providers, a nd attorneys. American LegalNet, Inc. www.FormsWorkFlow.com