INDEPENDENT EXERCISE OR WORK HARDENING / CONDITIONING PROGRAM REQUESTS CLAIMS DIVISION SFN 53630 (03/2010) 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 PLEASE PRINT OR TYPE USING BLACK OR BLUE INK. TO BE COMPLETED BY THE PROVIDER REQUESTING THE PROCEDURE. PLEASE SUBMIT TO CLAIMS ADJUSTER VIA MAIL OR FAX AT LEAST 24 HOURS PRIOR TO SCHEDULED START DATE. PROVIDER INFORMATION Date Person Requesting Review and Name of Facility Facility Address City State Phone Fax Zip Code INJURED WORKER'S INFORMATION Injured Worker's Name Claim Number Social Security Number Date of Birth Date of Injury ORDERING DOCTOR INFORMATION (PLEASE PROVIDE DOCTOR APPROVAL) Ordering Physician Address City Last Date of Service with Physician State Phone Zip Code INDEPENDENT EXERCISE PROGRAM DETAILS Cost Start and End Date Dates of Prior Treatments WORK HARDENING PROGRAM DETAILS Work Hardening Is IW working? Yes No If yes, name of employer Frequency/Total Number of Visits Therapist Name Employer phone # Start and End Date of Current Request WORK CONDITIONING PROGRAM DETAILS Work Conditioning Frequency/Total Number of Visits Therapist Name Start and End Date of Current Request CURRENT STATUS / ADDITIONAL INFORMATION AUTHORIZATION Approved Denied FL or C54 Created? Adjuster Date DETAILS ON AUTHORIZATION C59a American LegalNet, Inc. www.FormsWorkFlow.com