C59a INDEPENDENT EXERCISE REQUEST UTILIZATION REVIEW DIVISION SFN 53630 (05/2017) 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck ND 58506-5585 Telephone 701-328-5990 Toll Free Telephone 888-777-5871 Fax 701-328-3765 Toll Free Fax 866-356-6433 TTY (hearing impaired) 800-366-6888 www.w orkforce s afety.com Fax recent medical notes with request to 866-356-6433. To prevent a delay of your review complete required sections 1-3. SECTI ON 1 226 Injured worker 222s information Date Claim number Injured worker222s (First name) (L ast name) Date of injury Date of birth Social Security number* A rea of body SECTION 2 226 Facility requesting services Person to notify with decision Preferred method of notification of recommendation Telephone call OR Fax Telephone number Fax number Facility name F acility mailing address City State ZIP code Facility telephone number Facility fax number SECTION 3 226 Facility where services will be provided Cost Start date End date Facility name F acility mailing address City State ZIP code Facility Federal Tax ID Facili ty telephone number SECTION 4 226 Additional information *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. 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