WSI Designated Provider Selection Form

WSI Designated Medical Provider Selection Form

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  2. Designated Medical Provider Selection Form
    By action of the Ward County Commissioners, two local facilities have been designated as medical providers for work related injuries or illnesses. They are familiar with the Workforce Safety and Insurance claims process, treating such injuries, and in returning the employee to the job, even if only temporary light duty, as quickly as possible.
  3. Medical Arts Clinic
    400 Burdick Expwy E Minot, ND 58701 701-857-7840
  4. Trinity Medical Center
    1 Burdick Expwy W Minot, ND 58701 701-857-5135
  5. I wish to add the following designated provider(s) to seek treatment from in the event of a work place injury or illness:
  6. WSI may not pay for medical treatment by another provider unless a designated provider refers you or you list the provider above. Emergency care is exempt from the designated medical provider requirement.
  7. I have been informed of my employer's designated medical provider provisions.
  8. Leave This Blank:

  9. This field is not part of the form submission.