DESIGNATED MEDICAL PROVIDER SELECTION EMPLOYER SERVICES / PHS DIVISION SFN 58225 (06/2016) 1600 E Century Ave, Ste 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.workforcesafety.com Please complete and return a separate form for each business location. SECTION 1 ­ Employer information Date Name of contact person Email address Business location address City State ZIP code Employer account number Title of contact person Business/legal name Employer contact telephone number SECTION 2 ­ Designated medical provider (DMP) The DMP may be individual providers, clinics, and/or hospitals. Provider types may include medical doctors, chiropractors, osteopaths, dentists, optometrists, or any combination. The employer may select more than one DMP. The DMP selection does not apply to emergency care. Please indicate below if the DMP has been notified. If not, WSI will not recognize your selection(s). The designated medical provider(s) for the above location are; Name Address City State Telephone number DMP notified Yes Yes Yes Yes Yes Yes Yes Yes If you have additional DMP's, please attach additional pages as needed. No No No No No No No No SECTION 3 ­ Signature Employers must: Renew the DMP selection annually. Notify the provider(s), in writing, that they have been selected as their DMP. Notify their employees, in writing, of the DMP selection and their options. Employees have the right to add additional medical provider(s) to the above list (referred to as opting out). Employees must notify the employer of their additional medical provider(s) or opting out prior to an injury. If an employee opts out, he/she should retain a copy of page 2 of this form. By signing this document I agree to the terms and conditions stated above. Employer's signature Date P18 American LegalNet, Inc. www.FormsWorkFlow.com Designated Medical Provider Selection Form Do not return this form to WSI. This form should be kept by the employer and a copy given to the employee for their records. DMP selection should be reviewed annually. WSI may not pay for medical treatment by another provider unless a DMP refers the employee or the employee lists the provider below. Emergency care is exempt from the DMP requirement. The designated medical provider(s) for Name Address (employer's name) are City State Telephone number I have been informed of my employer's DMP program Employee's signature Employee's name (please print) Date I wish to add the following designated medical provider(s) to seek treatment from in the event of a workplace injury or illness Provider's name City Provider's name City Provider's name City Provider's address State Provider's address State Provider's address State ZIP code ZIP code ZIP code I have added the above designated medical provider(s) Employee's signature Employee's name (please print) Date American LegalNet, Inc. www.FormsWorkFlow.com