PHYSICIAN REQUEST FOR MEDICATION PRIOR AUTHORIZATION 1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE NUMBER (701) 328-5984 TOLL FREE NUMBER 1-800-777-5033 TOLL FREE FAX NUMBER 1-888-786-8695 TDD NUMBER (for the hearing impaired only) (701) 328-3786 WSI HelpLine 1-800-777-5033 Questions? Call us. Report Injuries Immediately. WORKFORCE SAFETY & INSURANCE CLAIMS DIVISION ND Fraud and Safety Hotline 1-800-243-3331 Report Fraud and Unsafe Work Conditions. SFN 54230 (01/2005) PLEASE PRINT OR TYPE USING BLACK OR BLUE INK Part 1: TO BE COMPLETED BY THE MEDICAL PROVIDER REQUESTING A MEDICATION, A MEDICATION DOSAGE, OR A MEDICATION INTERVAL THAT IS LISTED ON THE WSI EXCLUSION LIST. Injured Worker’s Date of Birth Injured Worker’s Name Physician’s Name Physician’s DEA Number Injured Worker’s Claim Number (if known) Physician’s Telephone Number Physician’s Fax Number Address City State Requested Drug Requested Dosage Diagnosis for this request Zip Code Qualifications for coverage: Please describe reason for request and duration of need: I certify that the above prescribe medication is medically necessary for this patient’s well being. In my opinion, this is reasonable and necessary in conformance with accepted standards of medical practice for the treatment of this condition. This has not been prescribed as a convenience to the patient, or solely due to the request of the patient. Physician’s Signature Date Part 2: FOR WORKFORCE SAFETY & INSURANCE USE ONLY Date Received Received by Approved - Effective dates of PA From: Approved by To: Date C157 completed Yes No Entered in CMS Yes No Pharmacy Notified Yes No Physician Notified Yes No Denied (Reason(s) PLEASE FAX COMPLETED FORM TO: Workforce Safety & Insurance Fax: (701) 328-3793 Phone: (701) 328-5973 M3 American LegalNet, Inc. www.FormsWorkflow.com