Work Hardening Or Conditioning Program Request {SFN 60800}

C59b WORK HARDENING OR CONDITIONING PROGRAM REQUEST UTILIZATION REVIEW DIVISION SFN 60800 (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 and provider222s order with request to 866-356-6433. To prevent a delay of your review complete required sections 1-5. SECTION 1 226 Injured worker 222s information Date Claim number Injured worker222s (First name) (Last name) Date of injury Date of b irth Social Security number* S ECTION 2 226 Facility requesting services Person to notify with decision Preferred method of notification of recommendation Telephone call OR Fax Telephone number Fa x number Facility name Facility mailing address City State ZIP code Facility telephone number Facility fax number SECTION 3 226 Ordering provider information Provider222s full name (MD, NP, PA) Provider222s NPI Date of recent office visit Clinic name Clinic mailing address City State ZIP code Clinic Federal Tax ID Clinic telephone number SECTION 4 226 Facility where services will be provided Facility name Facility address City State ZIP code Facility Federal Tax ID Facility telephone number SECTION 5 226 Work hardening/work conditioning program details Area of body/diagnosis Start date of current request End date of current request Total number of visits being requested Therapist name Is injured worker working? Yes No SECTION 6 226 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