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DESIGNATED MEDICAL PROVIDER Clear Fields NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES RISK MANAGEMENT DIVISION SON 81 (9-2012) We are participating in the Risk Management Workers Compensation Program.
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How to fill out designated medical provider return
How to fill out designated medical provider return:
01
Obtain the designated medical provider return form from your employer or workers' compensation insurance provider.
02
Fill in your personal information, including your name, address, and contact information.
03
Provide details about your injury or illness, including the date it occurred and a description of how it happened.
04
If you received medical treatment, list the healthcare provider's name, address, and contact information.
05
Indicate whether you have seen any other healthcare providers for the same injury or illness.
06
If applicable, provide any additional information requested on the form, such as your current work status or any work restrictions given by the healthcare provider.
07
Date and sign the designated medical provider return form, certifying that the information provided is accurate to the best of your knowledge.
08
Submit the completed form to your employer or workers' compensation insurance provider as instructed.
Who needs designated medical provider return?
01
Employees who have suffered a work-related injury or illness are typically required to fill out a designated medical provider return form.
02
Employers use this form to track and document the medical treatment received by their employees for workers' compensation purposes.
03
Workers' compensation insurance providers also require this form to ensure proper payment and coverage for medical expenses related to the injury or illness.
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What is designated medical provider return?
Designated Medical Provider Return is a form that must be submitted by medical providers who have been designated by an employer to provide medical treatment to injured employees.
Who is required to file designated medical provider return?
Medical providers who have been designated by an employer to provide medical treatment to injured employees are required to file designated medical provider return.
How to fill out designated medical provider return?
To fill out designated medical provider return, medical providers need to provide information such as details of the treatment provided, the dates of service, and the charges incurred.
What is the purpose of designated medical provider return?
The purpose of designated medical provider return is to ensure that accurate and timely information related to medical treatment provided to injured employees is documented and reported.
What information must be reported on designated medical provider return?
Information such as details of the treatment provided, the dates of service, and the charges incurred must be reported on designated medical provider return.
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