Doctor's assessment of an injured worker's diagnosis, work release, physical capabilities and restrictions, follow-up plan, and MMI / likely PPI status.
- Completed by
- Treating physician
- Format
- Fillable PDF
- Language
- English
North Dakota WSI forms for physicians and treating providers
Workforce Safety & Insurance forms for capability assessments, utilization review, medications, devices and dispute resolution, with who completes each one.
North Dakota's workers' comp forms come from Workforce Safety & Insurance (WSI), and each carries an SFN number. The form treating physicians meet most is the Capability Assessment (C3, SFN 58550): diagnosis, work release, physical capabilities and restrictions, follow-up plan, and MMI or likely permanent impairment. Prior authorization for imaging, surgery and other services goes on the UR-C Prior Authorization Review Request (SFN 58385), and medication requests on the M11 (SFN 58430).
Return the C3 to WSI right away. The physician completes Sections 2 to 5 and signs Section 6, the employee signs the release, and the form also asks whether function improved with opioid therapy. The UR-C goes to WSI Utilization Review with documentation of medical necessity. Chiropractors request more visits on the UR Chiropractic Review Request (SFN 59693), and providers can ask for binding dispute resolution after a utilization review appeal (SFN 19605).
Physicians, NPs and PAs
Requests WSI utilization-review prior authorization (or appeal) for imaging, surgery and other services, with ordering-provider and servicing-facility details.
- Completed by
- Ordering provider (MD, NP, PA) or their office
- Format
- Fillable PDF
- Language
- English
Requests prior authorization (or appeal) for an independent exercise program (e.g., gym membership) for an injured worker.
- Completed by
- Requesting provider/facility (typically the treating physician or therapist)
- Format
- Fillable PDF
- Language
- English
Requests precertification for a non-emergent facility-to-facility air ambulance transfer and documents why air transport is medically necessary.
- Completed by
- Requesting facility with certifying provider (MD, NP or PA)
- Format
- Fillable PDF
- Language
- English
SFN 19605Binding Dispute Resolution Request
Lets a medical provider request binding dispute resolution of a WSI decision on proposed or provided treatment after utilization-review appeal.
- Completed by
- Treating (or other) medical provider
- Format
- Fillable PDF
- Language
- English
Chiropractic
SFN 59693UR Chiropractic Review Request
Requests utilization review authorization (or appeal) for additional chiropractic visits, listing manipulation codes, visits requested and progress.
- Completed by
- Treating chiropractor
- Format
- Fillable PDF
- Language
- English
Other providers
Requests WSI prior authorization for a medication, dose or interval, or for a brand-name drug when generics failed.
- Completed by
- Prescribing provider
- Format
- Fillable PDF
- Language
- English
Requests authorization for a TENS unit, muscle stimulator or combination electro-medical device for an injured worker.
- Completed by
- Ordering provider (with the treating therapist's details)
- Format
- Fillable PDF
- Language
- English
More US forms
How this list is checked
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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Frequently asked questions
Who completes the WSI Capability Assessment (C3)?
The treating physician completes Sections 2 to 5 (medical assessment, physical capabilities, follow-up plan, and MMI or likely permanent impairment) and signs Section 6. The employee signs the release section. The form also asks whether function increased because of opioid therapy. Return it to WSI immediately.
How do I request prior authorization from WSI?
Use the UR-C Prior Authorization Review Request (SFN 58385) for imaging, surgery and other services. The ordering MD, NP or PA, or their office, completes both pages, including the servicing facility's details, and faxes them to WSI Utilization Review with documentation supporting medical necessity. The same form is used to appeal. Medications have their own request, the M11 (SFN 58430), and independent exercise programs such as a gym membership use the C59a.
What if I disagree with a WSI treatment decision?
After a utilization review appeal, a medical provider can request binding dispute resolution on the Binding Dispute Resolution Request (SFN 19605). Complete the whole form, including the Section 4 narrative, and submit it to WSI Medical Services with a summary of the dispute and the medical documentation. It covers decisions on proposed or provided treatment.
How do I order a TENS unit for a WSI claim?
Use the Electro Medical Device Request (M5, SFN 54391). The ordering provider completes it, with the treating therapist's details, for a TENS unit, muscle stimulator or combination electro-medical device, and submits it to WSI Medical Services with supporting documentation.