Requests WSI prior authorization for a medication, dose or interval, or for a brand-name drug when generics failed.
- Completed by
- Prescribing provider
- Issued by
- North Dakota Workforce Safety & Insurance (WSI)
- Format
- Fillable PDF
- Language
- English
ND WSI M5 Electro Medical Device Request (TENS)
North Dakota Workforce Safety & Insurance requires prior authorization for electro-medical devices, and the M5 is the request form. The ordering provider picks the unit type (TENS, muscle stimulator, combination or other), names the treating therapist and facility, says whether the unit should ship to the physical therapist, and attaches the prescription or order with supporting documentation.
Who completes it
The ordering provider completes the form, giving name, specialty and clinic in Section 4, along with the claim details, the therapist's information and the device requested. The injured worker does not complete any part.
Submitting and payment
- How to submit it
- Send the M5 with the prescription or order and supporting documentation to WSI's Medical Services Division, or submit the prior authorization in myWSI.
Good to know
- WSI's durable medical equipment guide says electro-medical units must be supplied by CPR Medical.
- H-Wave electrical stimulation units are listed as not covered; the guide's covered electro-medical items are a TENS unit, a neuromuscular stimulator and a combination unit.
- WSI reviews DME requests only on accepted claims and requires a prescription or order from the treating provider.
- Section 1 includes the worker's address and phone, and Section 2 asks whether to ship the unit to the physical therapist.
Get the official form
Download the current version from the source each time; forms change without notice.
Electro Medical Device Request
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
Does North Dakota WSI cover TENS units?
Yes, with prior authorization. WSI's DME guide lists the TENS unit, neuromuscular stimulator and combination unit as electro-medical devices requiring prior authorization through the M5 form or myWSI, with units supplied by CPR Medical. H-Wave units are not covered.
What should be attached to the M5?
The prescription or order for the device and supporting documentation, which Section 3 confirms is attached. WSI's guide says it requires a prescription or order for durable medical equipment from the treating provider and reviews DME requests only on accepted claims.
Can the device be shipped to the patient's therapist?
Yes. Section 2 asks for the treating therapist's name, facility, address and telephone, and has a yes or no question on whether the unit should be shipped to the physical therapist. The worker's own address and telephone are recorded in Section 1.