PROVIDER'S REQUEST FOR MEDICATION PRIOR AUTHORIZATION MEDICAL SERVICES DIVISION SFN 54230 (08/2016) 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 SECTION 1 ­ Injured worker information Claim number Date of birth Injured worker's (First name) (Last name) Date of request SECTION 2 ­ Provider information Provider's name Address City State ZIP code NPI number Telephone number Fax number SECTION 3 ­ Medication information Medication name Diagnosis for this request Select one of the following reasons for the request Prior authorization for medication, medication dosage, or medication interval Describe reason for request and duration of need Strength Dosage form Prior authorization for brand medication Has injured worker tried a generic? Yes* Adverse reaction Inadequate response No *Include medical notes from injured worker's file detailing objective medical evidence of the adverse reaction and/or inadequate response to the generic equivalent medication. SECTION 4 ­ Signature I certify that the above prescribed 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 medication is not prescribed as a convenience to the patient or solely due to the request of the patient. Provider's signature Date Fax this authorization form and supporting documentation to 888-786-8695 M11 American LegalNet, Inc. www.FormsWorkFlow.com