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2. 
3. 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.
5. Medical Arts Clinic
   400 Burdick Expwy E Minot, ND 58701 701-857-7840
6. Trinity Medical Center
   1 Burdick Expwy W Minot, ND 58701 701-857-5135
8. I wish to add the following designated provider(s) to seek treatment from in the event of a work place injury or illness:
10. Provider's Name
12. Provider's Address
13. City
14. State
15. Zipcode
19. Provider's Name
21. Provider's Address
22. City
23. State
24. Zip
28. Provider's Address
30. Provider's Address
31. City
32. State
33. Zip
37. 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.
39. Signature of Employee*
    I have been informed of my employer's designated medical provider provisions.
40. Date*
    Date
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

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