North Dakota Workforce Safety & Insurance covers gym memberships and aquatic or pool facility memberships as an Independent Exercise Program, but only with prior authorization. Form C59a is the paper route for that request, or for an appeal of a denial. It lists the service, body part, start and end dates, the requesting facility, and the servicing facility where the worker will exercise.
The requesting provider or facility, typically the treating physician or therapist, completes all five sections and attaches supporting documentation. The injured worker does not complete or sign any part.
Download the current version from the source each time; forms change without notice.
Independent Exercise Program Request
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.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
WSI's prior authorization guide lists gym memberships and aquatic or pool facility memberships under the Independent Exercise Program, which requires prior authorization. Submit the request in myWSI or on Form C59a with supporting documentation, naming the servicing facility and the program's start and end dates.
WSI's guide says utilization review is completed within 3 business days once all required information has been received. Missing supporting documentation or facility details hold up that clock, so attach the clinical notes that justify the program when sending the form.
Yes. Check Appeal in Section 2 of the same form, or appeal in myWSI, and include new, relevant medical information that disputes the rationale given in the UR notification letter. If the dispute remains after the appeal, binding dispute resolution is available on SFN 19605.