Workforce Safety & Insurance reports and prior authorizations, Medicaid service authorizations, the NDHSAA sports physical and public health reports from North Dakota.
North Dakota's forms come from Workforce Safety & Insurance (WSI), the Department of Health and Human Services, the school activities association and the Tax Commissioner. Clinicians meet these most: the WSI Capability Assessment (C3, SFN 58550), WSI prior authorization requests such as the M11 for medications, the NDHSAA Preparticipation Physical Evaluation Form and the Medicaid service authorization request (SFN 511). This page lists all 22 North Dakota forms, grouped by program.
Return the C3 to WSI right after the visit. It covers work release, restrictions, MMI and whether function improved on opioid therapy. Most WSI requests are faxed with supporting notes. NDHSAA physicals done on or after April 15 count for the next school year. The state's Certificate of Immunization and/or Exemption (SFN 16038) carries every exemption type, and a medical exemption needs a licensed physician's signature. Vero Documents fills PDF forms from the visit note and the chart; you review and sign.
Doctor's assessment of an injured worker's diagnosis, work release, physical capabilities and restrictions, follow-up plan, and MMI / likely PPI status.
Requests WSI prior authorization for a medication, dose or interval, or for a brand-name drug when generics failed.
Requests WSI utilization-review prior authorization (or appeal) for imaging, surgery and other services, with ordering-provider and servicing-facility details.
SFN 59693Requests utilization review authorization (or appeal) for additional chiropractic visits, listing manipulation codes, visits requested and progress.
Requests prior authorization (or appeal) for an independent exercise program (e.g., gym membership) for an injured worker.
Requests authorization for a TENS unit, muscle stimulator or combination electro-medical device for an injured worker.
Requests precertification for a non-emergent facility-to-facility air ambulance transfer and documents why air transport is medically necessary.
SFN 19605Lets a medical provider request binding dispute resolution of a WSI decision on proposed or provided treatment after utilization-review appeal.
Member's medical provider certifies the medically appropriate mode of non-emergency medical transportation (e.g., wheelchair van, stretcher).
Requests authorization to exceed ND Medicaid service limits for chiropractic, PT/OT/speech therapy units and other limited services.
Requests ND Medicaid service authorization for surgical/medical procedures, devices and physician-administered drugs.
Annual pre-participation health history screening and physical examination clearance required for NDHSAA-sanctioned sports.
Single North Dakota certificate documenting a student's immunizations and any medical, history-of-disease, religious, philosophical or moral exemption for school and child care.
Medical statement supporting a meal modification (disability-related diet, allergy, texture or substitution) in the USDA school meal programs (NSLP/SBP), as required by 7 CFR 210.10(m) and Section 504/ADA.
Health care provider certifies that the patient has a debilitating medical condition; the certification is linked to the patient's registry ID card application.
Mandated reporter's written report of known or suspected child abuse or neglect (NDCC 50-25.1) to Child Protection Services.
SFN 7630Report of a notifiable disease or condition (NDCC 23-07; NDAC Article 33-06) by a clinician, facility or laboratory to ND HHS.
Mandated reporter's written report of suspected abuse, neglect or exploitation of a vulnerable adult (NDCC 50-25.2) to Vulnerable Adult Protective Services.
Physician certifies that an applicant under 65 is permanently and totally disabled for the North Dakota homestead property tax credit or renter's refund (NDCC 57-02-08.1).
Clinician confirmation that the applicant is blind, paraplegic or has lost the use of one or both arms, for a permit to hunt game or shoot nongame fish with a crossbow.
Clinician certification that a licensed hunter cannot walk for hunting or has lost use of an arm at or below the elbow, for a permit to shoot from a stationary motor vehicle on private land.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The treating physician completes Sections 2 to 5: the medical assessment, physical capabilities, follow-up plan, and MMI and likely PPI status, then signs in Section 6. The form also asks whether function increased because of opioid therapy. The employee signs the release section. Return the C3 to WSI immediately by fax. It is a fillable PDF, also known as SFN 58550.
Use the form for the request type. The M11 covers a medication, dose or interval, or a brand-name drug when generics failed. The UR-C (SFN 58385) covers imaging, surgery and other services; fax both pages to WSI Utilization Review with documentation. Chiropractors use SFN 59693, the C59a covers independent exercise programs, and the M5 covers TENS and other electro-medical devices. After a utilization review appeal, a provider can request binding dispute resolution (SFN 19605).
One school year. An NDHSAA physical done on or after April 15 counts for the following school year. An MD, DO, PA or NP completes the Physical Examination Form and the clearance on page 4. The clearance form is filed with the school office, and the medical facility keeps the health history.
Online, in the state's registration system. The patient starts the application and enters the provider's name and email. The provider receives an email request and completes the written certification of a debilitating medical condition in the system, which links it to the patient's registry ID card application. Certifying providers are North Dakota-licensed physicians, PAs or APRNs. Minor patients, under 19, have separate application instructions.