FEE SCHEDULE REQUEST MEDICAL SERVICES DIVISION SFN 52478 (08/2006) Fee Schedules 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com Fee Schedules Ambulatory Surgical Center Medicine Anesthesia Pathology & Laboratory Chiropractic Physical Therapy Chiropractic Radiology Radiology DME (Durable Medical Equipment) Surgery Evaluation & Management Ambulance Inpatient Hospital Home Health Care Outpatient Hospital To comply with copyrighted material by the American Medical Association, WSI must have providers requesting a copy of a schedule agree to the following disclaimer. (See Attached). If you accept this agreement, please sign the acceptance and send or fax this form to WSI. Once WSI has received the signed request form, we will be happy to e-mail the most recent version of the selected fee schedule to you. TO RECEIVE YOUR FEE SCHEDULES RETURN THIS ORDER FORM BY MAIL OR FAX TO: Please send the above requested publications to: (Please type or print) Your Name Company Name Medical Services Division Workforce Safety & Insurance PO Box 5585 Bismarck, ND 58506-5585 City Fax: 701-328-3793 State Address Zip Telephone Number E-mail Address American LegalNet, Inc. www.FormsWorkflow.com EXHIBIT B End User Agreement: LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”) CPT only copyright 2004 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. You, your employees and agents are authorized to use CPT only as contained in North Dakota Fee Schedule solely for your own personal use in directly participating in healthcare programs administered by WSI. You acknowledge that AMA holds all copyright, trademark and other rights in CPT. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, CPT Intellectual Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications are available at the American Medical Association Web site, www.amaassn.org/go/cpt. U.S. Government Rights This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements. Disclaimer of Warranties and Liabilities. CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The American Medical Association (AMA) does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with WSI, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement. Should the foregoing terms and conditions be acceptable to you, please indicate by signing below. ACCEPTANCE Name Date American LegalNet, Inc. www.FormsWorkflow.com