North Dakota Workforce Safety & Insurance requires the M13 for a non-emergent air ambulance transfer between facilities for an injured worker, while emergent transport needs no prior authorization. The requesting facility identifies the receiving facility and physician, the air carrier and the scheduled transfer date. A certifying provider checks the clinical reasons air transport is medically necessary and certifies the choice of carrier.
The requesting facility completes the claim, facility, transport and notification details, and a certifying provider (MD, NP or PA) gives name and NPI and checks the medical-necessity reasons. The Section 6 signer marks whether they are an EMT, paramedic, trained first responder, physician, physician assistant or APRN.
Download the current version from the source each time; forms change without notice.
Non-Emergent Air Ambulance Facility-to-Facility 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.
No. WSI's prior authorization guide says emergent transport requires no prior authorization. The M13 applies to non-emergent facility-to-facility air ambulance transfers, and the guide says to submit it by the end of the next business day.
Section 3 names the certifying provider, who must be an MD, NP or PA, with an NPI number. The Section 6 certification of preferred carrier is signed with a printed name, and the signer checks whether they are an EMT, paramedic, trained first responder, physician, physician assistant or APRN.
Section 4 names the air ambulance carrier. In Section 6 the signer certifies that the patient's condition requires air transport due to time or geographical factors and that they reviewed WSI's list of carriers holding a Memorandum of Understanding with WSI, then discloses any financial or employment relationship with the supplier.