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HomeMy WebLinkAboutFirst Report of Injury ATTN HANDLER igIRSI REPORT OF INJURY FORMS F /ORKERS COMPFNSRTT CLAIMS ---„) ` . ■ Al 21. Date of first CI • day of lost time: 23. Return to work date: L1 ‘ed met m id sumo o"441 wo,,,„0,01,2,%.4,400*""61. - I . We request your assistance when completing First Report of Injury forms. Please write or type NO LOST TIME, NLT OR NONE in Box 21 when there is no lost time associated with an injury. Here's why: When Box 21 is left blank, we do not know whether it was an oversight, there was no lost time or the person completing the form did not have the information. To clarify this, we have to interrupt your business day, often with several calls, to reach the person who has the information we need. This delays the investigation process, payment of benefits and our ability to promptly answer questions related to the claim. We would appreciate it if you would share this request with everyone in your organization who is responsible for completing First Report of Injury forms. Thank you for your cooperation. Illiesota Workers' Compensation, INSTRUCTIONS FOR EMPLOYERS WHAT TO REPORT State law requires that you report any and all injuries and illnesses that your employees believe are work-related.The League of Minnesota Cities Insurance Trust will then determine if any workers'compensation benefits are payable to the injured employee. Remember,filing a First Report of Injury with us does not mean that you are admitting any liability. It means only that you are reporting a claimed injury or condition which your employee thinks is related to work activities. WHO REPORTS AN INJURY The injured employee is required to report an injury to you,the employer,within 180 days of its occurrence.You,the employer, are then required to report that claimed injury to us on a First Report of Injury form. It is neither the injured employee's responsibility to report the injury to us nor is it your insurance agent's duty. Do not ask the injured employee or your agent to complete the form. If they cause any delay in reporting the injury to us,you, the employer,can be penal- ' ized by the Minnesota Department of Labor and Industry. WHEN TO REPORT AN INJURY If an employee is killed or suffers a life-threatening injury(amputation of limb, massive internal injuries, etc.)you must report by phone to The League of Minnesota Cities Insurance Trust within 48 hours of the occurrence.You must also send a completed First Report of Injury form to us within 7 days of the injury. You must report any other work-related injury or illness within 10 days of your first knowledge of its occurrence. If the employee's supervisor or manager knows about the injury,then you, the employer, have knowledge of it even if your home office or headquarters staff is unaware of the injury. The injury must be reported on a First Report of Injury form and we must receive it within 10 days. Because of possible delays by the Postal Service,we recommend that you complete and mail the original First Report on the same day you are notified of the injury. Do not wait for the employee to return to work or for medical bills or other information. Any delay in this process can result in a penalty assessment against you by the Minnesota Department of Labor and Industry. You can be fined up to$500 for late reporting. If that late report results in late payment of benefits to your employee, you can be penalized for an amount that is a percentage of the delayed payment. It is very important that you report all claimed injuries as soon as possible. HOW TO REPORT AN INJURY State law requires that you use a Minnesota First Report of Injury form.Always keep a supply of forms on hand.When your supply runs low, use the order form sent with this folder to request more forms. When an accident occurs, have the employee's supervisor complete the Supervisor's Report of Accident(SRA). This form will assist in your internal investigation of the accident and whaficaused it.Then you, the employer, should complete the First Report of Injury form using information from the SRA, personnel records, and elsewhere. If there are any unusual circumstances or you need to provide more information,you should attach a letter to the report. Send the original First Report and SRA to The League of Minnesota Cities Insurance Trust. Keep a copy of each for your records. Also give a copy of the First Report of Injury to the injured employee; this is required by law. Detailed, line-by-line instructions for the First Report begin on Page 3. REMINDERS AND ADVICE • If an employee begins to lose time from work after you've mailed the First Report, call us immediately to let us know. Then we can pay any benefits due on time and you can avoid any penalties for late payment. • Call us as soon as an employee returns to work after a work-related injury.We can then discontinue time-loss benefits and avoid the possibility of overpaying your employee. • Promptly send us all injury-related medical bills you or your employee receive. Medical providers often bill only one party, so if you receive a bill, it probably means that we have not. Before we pay a bill,we review it to ensure that its related to the work injury and we request medical records for it The law allows us 30 days from the date we receive those records to pay a bill so it may sometimes be several months from the date of treatment before we're able to pay. • Do not pay medical bills for your employees'work-related injuries. First, it may be illegal for you to do so. Second, by paying a bill, you may be legally accepting liability for an injury which is not really work-related. Third, because of the Medical Fee Schedule,we can often pay less than what the medical provider charges which saves you money. E S • LMC145 University Avenue West, St. Paul, MN 55103-2044 League of Minnesota Cities Phone: (612) 215-4173 Cities promoting excellence Fax: (612) 281-1297 • TDD (612) 281-1290 This folder contains important documents and instructions for filing claims for your employees. Please read everything carefully now so you will know what to do when an injury occurs. If you have any questions, please contact your agent or The League of Minnesota Cities Insurance Trust. CRITICAL INFORMATION Any serious (life threatening) injury or injury causing death must be reported to us by phone immedi- ately. ( 9) � 1 rY 1 rY 9 p YP ately. Dial (612) 215-4170. In all other situations state law requires you, the employer, to report all injuries and illnesses which your employees claim are related to work. You must report their claim using a FIRST REPORT OF INJURY form. The League of Minnesota Cities must receive the original report within 10 days of the date you have knowledge of the claimed injury. The law also requires prompt payment of any benefits which may be due. Payment for lost wages must be made within 14 days of the first day of lost time from work. The Department of Labor and Industry can and does impose fines and penalties against employers if they do not comply with these standards. To avoid substantial penalty expenses for late reporting of an injury or for late payment for benefits, you must report injuries and lost time from work to us as soon as possible. To help you do that, you will find detailed instructions for completing the First Report of Injury form on Page 3 of this folder. If you need additional copies of any of the enclosed forms, please complete and mail the order form sent with this folder. PREVENT WORK INJURIES For your benefit and assistance, we offer safety services which can be tailored to your needs to help prevent work-related injuries. Our Loss Control Representatives are available for consultation regarding safety in the workplace and for safety surveys of your facilities. They can also assist you in compliance with OSHA regulations and the development of your own program of accident prevention and loss control. These services are provided at no additional charge to you. Call (612) 281-1200 to schedule a visit or for more information on safety and loss control topics. MANDATORY FRAUD NOTICE A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Minnesota Statute 60A.955. LM 2530(2/98) • Do not deliberately obstruct*mot to prevent an employee from seekinnrkers'compensation benefits. If you do, you could be liable for any workers'compensation benefits plus triple damages to that employee. By law you must post the name and address of your workers'compensation carrier(The League of Minnesota Cities Insurance Trust)in a conspicuous place. You may use our"Employees' Rights"poster for that purpose. If an employee claims a work-related injury, report it to us along with all relevant information. Let us investigate and determine if any workers'compensation benefits are due;we are experts in Minnesota workers'compensation. • Don't ignore your injured employees. Communicate with them regularly and let them know you are concerned about them. It is especially important, if they are losing time from work,that you keep them mentally"connected"to their job. If at all possible, provide light duty or part-time work to help return them to health and productivity as soon as possible.This is not only good for your employees, it also helps to reduce your claim costs. • Be accessible and provide us with the information we need when we request it. This will allow us to be more effective in managing your claims and controlling your workers'compensation costs. FIRST REPORT OF INJURY INSTRUCTIONS Box 1 Enter the case number from your company's OSHA 200 log. Box 2 Enter the injured employee's name. Box 3 Enter the injured employee's social security number. This must be completed because the State of Minnesota uses it as its file number. Box 4 Enter the employee's current mailing address including the county. Box 5 Enter the date that the injury occurred. If not known,enter the approximate date or"unknown". Box 6 Indicate the employee's gender. Box 7 Indicate the employee's marital status. Box 8 Enter the employee's job title or a description of the work done for your organization (Example: Class A Machinist, Carpenter's Helper). Box 9 Enter the employee's birth date. Box 10 Enter the date that the employee began working for your organization. Box 11 Provide the name of the department or unit where the employee usually works(e.g.welding dept., loading dock, ac- counts receivable unit). If your organization has no formal departments, leave this box blank. Box 12 Enter the employee's home phone number including area code. Box 13 If the employee is in a union apprenticeship program or some other formal apprentice program indicate that in this box. Box 14 Enter the employee's average gross weekly wage before any deductions for taxes, etc. If the employee is salaried, write"salary"and the gross amount and the period it is paid for(e.g. $500/week salary, $2,000/month salary). If you are continuing to pay full wages or sick/vacation leave beyond the first day of lost time, indicate this by writing in"full wage continuation". Box 15 Enter the hourly wage rate for employees paid by the hour. Box 16 Enter the usual number of hours the employee works each day. Box 17 Enter the usual number of days the employee works each week and indicate which days are usually worked e.g. M-F, Tu-Su, or M,W,F. Box 18 If the employee receives meals or lodging from you as part of their pay, enter their value here. If the employee also works somewhere else full or part-time,enter their average weekly earnings at that job and provide us with the name of the other employer. Box 19 Put an X by the description which best indicates the employee's work status. If the employee is a police officer or firefighter, indicate their smoking habits. Box 20 Indicate the location where the injury occurred and whether or not it occurred on your premises. Box 21 If your employee has lost any time at all(even just 10 minutes)from work, you must report it. Enter the date when lost time first occurred. If there has been no lost time,write"NONE"in the box. Box 22 Enter the date on which you first had knowledge of your employee's injury. Box 23 If the employee has already retureto work,enter the date returned. If the em*ee has not returned to work, leave this box empty. Box 24 Sometimes employee's are injured but don't lose time from work until days or weeks later or they lose time but don't notify you that it is related to their work injury. In any case, provide the date you were notified that the employee was losing time from work due to a work injury. Box 25 If your employee has died as a result of their work-related injury or illness,enter the date of death in this box.A work- related death or life-threatening injury must be reported to us by phone immediately. Box 26 Indicate the approximate time that the injury occurred. Box 27 Enter the type of injury he/she has. Indicate all body parts which were injured. Be specific.Write"left low back and left index finger" rather than"back and hand". If the injury is not obvious,write something like"possible fracture"or"appar- ent allergic reaction". Box 28 Briefly but accurately describe the circumstances that caused the injury. Don't just write"fell onto sidewalk"if in fact the employee was"on roof repairing chimney, safety harness broke, fell 20'onto concrete sidewalk". Also, circumstances surrounding the injury are complex, unusual, or suspicious, attach a detailed explanatory letter to the First Report of Injury form and SRA that you send to us. Box 29 Provide the name, address, and phone number of the doctor who treated the employee for the injury. If the employee received no medical treatment,write"first aid only"in this box. Box 30 Provide the name,address and phone number of the clinic or hospital where the employee was treated for the injury. Box 31 Provide the names of coworkers who may have witnessed the accident or who worked with the employee on the date of the injury.We may need to contact these people to obtain more information about the circumstances that lead to the injury. Box 32 Enter the name and address of your organization. If you do business using a different name than you are insured under, please indicate that. For example: John Doe dba J.D. Enterprises or J.D. Widgets Division of John Doe Enterprises. Box 33 Enter the date that you,the employer, completed the form. Box 34 Enter your Unemployment Insurance ID number.This number is assigned to you by the Department of Economic Security. Call them at(612)296-6141 if you do not know your ID number. Box 35 Enter the proper SIC code for your organization.This number is also assigned by the Department of Economic Secu- rity. Call them at(612)296-6141 if you do not know your SIC code. If you know the payroll classification code for the injured employee, enter it in the box to the right of Box 35. Box 36 Enter the name and work phone number of the injured employee's supervisor. Box 37 Enter the name,title, and work phone number of the person•in your organization whom we should contact to obtain more information about this claim. Boxes 38-44 Do not fill in these boxes.The League of Minnesota Cities Insurance Trust will complete this part of the form. Minnesota Department of Labor and Industry .OSHA Case# Workers'Compensation Division First Report of Injury 443 Lafayette Road North St.Paul,MN 55115-4305 See instructions on reverse side.Type or print. (612)296-2432 All dates must be entered in MM/DD/YY format. F R 0 1 Employee 2. Name(last,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: 4. Home address(include county and zip) 5. DATE OF CLAIMED INJURY: Do not use this space 6.Sex:❑Male❑ Female 7. Marital Status: ❑ Married ❑ Single 8.Occupation: 9.Date of Birth 10.Date Hired: 11. Regular Dept.: 12.Home Phone No.(A/C, No.) 13.Apprentice: ❑ No❑Yes ( ) WAGE INFORMATION 15. Rate per hour: 16.Hours per day: 14.Average wage/week 17. Days per week: 18.What is the weekly value of MEALS: LODGING: 2nd INCOME: 19.Employment Status:❑Full time ❑Part time ❑Seasonal ❑Volunteer(attach 26 week wage statement for part-time or irregularly scheduled employee) OCCURRENCE 20.PLACE(include dept.&full address) 21.Date of first day 22.Date employer of any lost time: notified of injury: 24.Date employer notified 23. Return to work date: of lost time: 26.Time of day ❑AM 25.Date of death: On employer's premises? ❑Yes ❑No of injury: ❑ PM 27. Describe nature or injury or illness in detail,be specific(include part(s)of body affected,e.g.amputation of right index finger at 2nd joint,fractured arm) 28.Describe employee's activities when injury occurred with details of how event occurred(include name of other individuals involved,tools,machinery, objects,vapors,chemicals,radiation,unnatural motions of employee) 29.Physician(full name,title,address and phone number) 30.Hospital/Clinic(name and address) 31.Witness and phone number: ( ) ( ) EMPLOYER 32.Legal name&mailing address include.zip 34.Unemployment ID No.: OAK PARK HEIGHTS 33.Date form completed: PO BOX 2007 35.SIC code Payroll class code OAK PARK HEIGHT,MN 55082-2007 36.Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number: ( ) ( ) SEND REPORT IMMEDIATELY-DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.Carrier(name,address&phone number) 39.Insurer ID No.: 40.Adjuster name&address: ® Self-Insured Berkley Administrators League of Minnesota Cities Insurance Trust 41.Insurer Class Code: 145 University Avenue West St. Paul, MN 55103-2044 42.Carrier Claim Number -43.Date insurer received notice: 44.Adjuster ID No.: 02-000729 0698639002 LI-20320-05(5J96)Original to Berkley Administrators.Copies to:Employer,Employee and Workers'Compensation Division(if no insurer) LM 2510 (7/97) • Important Notice S The filing of this report is not an admission of liability. It should be filed with your insurance carrier whenever anyone believes a work-related injury or illness has occurred. The prompt filing of this report with your insurance carrier and the Department of Labor and Industry is required by law. Failure to report the claim within ten days may subject you to penalties. (if you are self- insured, your time limit is 14 days.)You should file this report immediately with your insurer. This will allow your insurer as much time as possible to investigate the claim. Even if the claim is questionable, it is important that you report it promptly. If you question the claim, attach any additional information to this report. Each case should also be recorded on your OSHA 200 log, if necessary. General Instructions to the Employer Death or serious injury arising from employment must be reported to the Department of Labor and Industry within 48 hours of the occurrence. You may initially report by telephone (612)297-1272, telegraph, facsimile (612)215-0170 or personal notice within 48 hours, but that notice must be followed by the filing of this report with your insurer within seven days of the occurrence. If a reported injury subsequently results in death, a report of the death must be made to the Department and your insurer within 48 hours of when you are notified of the death. Whenever you become aware of any work-related injury or illness that requires medical care or lost time from work, you must report the injury to your insurer as soon as possible. If the employee cannot work for a period of more than three days, the workers' compensation claim must be made on this form and reported to your insurer within ten days. However, your insurer may require that you file it sooner. Your insurer will forward the form to the Department of Labor and Industry if necessary. Please print or type. It is absolutely essential that you fill in all the information you can. Each piece of information is needed to determine liability and entitlement to benefits. Failure to complete the form may result in delayed processing and possibly penalties. Provide copies to your insurance carrier and your injured worker. If the claim results in the employee's inability to work for a period of more than three days, send a copy of this report to the employee's local union office. Specific Instructions to the Employer on Filling Out the First Report of Injury Form • Item 1: OSHA Case#. Fill in the case number from the OSHA 200 log. • Items 14-19: Be sure to fill in all the wage information, If the claimant does not work a regular work week. Attach a 26 week wage statement and your insurer will calculate the appropriate average weekly wage. • Item 21: Fill in the first day the employee lost any time from work, even if you paid the employee for the full day. • Item 22: Be sure to fill in the date you first became aware of the injury or illness. This is used to determine whether the form is filed late.You have ten days from the date you became aware of this injury to report this to your carrier. • Item 23: If the employee has not returned to work by the time you are filing this form, leave the box blank. If the employee has returned to work and you indicate this on the form, be sure to notify your insurer immediately if the injured employee misses time later due to this injury. • Item 27: Be as specific as possible in describing the injury. Indicate(1)the nature of the injury: cut, sprain, burn, etc. and (2) parts of body injured: back, arm, hand, etc. • Item 28: Be as specific as possible in describing the event. Indicate(1)the name of the object or substance involved: machine, tool, chemical, etc. and(2)type of accident: fall, struck by, etc. • Items 34 and 35: unemployment ID and SIC code. These numbers are assigned by the Department of Economic Security. Call them at(612)296-6141 if you don't have a SIC or unemployment insurance number. • Do not fill in items 38-44. Your insurer will add this information. Any person who,with intent to defraud, receives workers'compensation benefits to which the person is not entitled by knowingly misrepresenting, misstating or failing to disclose any material fact is guilty of theft and shall be sentenced pursuant to section 609.52,subdivision 3. • LI-20320-05(5/96)Original to Berkley Administrators.Copies to:Employer,Employee and workers'Compensation Division(if no insurer) LM 2510(7/97) Landmark Insurance ervices M O Page 1 PO BOX 188 ACCOUNT NO. OP DATE Forest Lake,MN 55025 OAKPA-1 TL 04/21/98 Phone: 612-464-3333 Support:612-464-7596 POLICY INFORMATION POLICY# 0200072911 TYPE EFFECTIVE EXPIRATION WC 07/07/97 07/07/98 City of Oak Park Heights @ [] [ Mike Robertson,City Admin. D i 14168 N 57th St, Box 2007 Stillwater,MN 55082 APR 2 2 1998 Mr.Robertson Re: Dividend Check You will shortly be receiving a dividend check from League of MN Cities Workers ' Compensation Program in the amount of $5, 217 . 00 . These surplus funds are available to member cities because cities ' loss experience has improved significantly over the past several years . The amount returned to each city is based on each member' s total earned premiums and total losses for all the years the city has been a member of LMCIT. Attached is a copy for your review. Please call our office if you have any questions. Thank you. Sincerely, y, Tr cey Lun • 1998 LMCIT Workers Compensation Program Dividend p 9 Cif Oak Park Heights Total Earned Premium $232,894 Total Incurred Losses $8,740 Adjusted Losses $8,740 Dividend $5,217 • • Berkley Administrators 1 1997 PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN t5426 Phone (612)544-0311 • Fax (612) 591-7404 CITY OF OAK PARK HEIGHTS Enclosed is your: • ❑ Coverage Document for Minnesota Workers' Compensation Please carefully review your Policy or Agreement, the Information Page and any Endorsements to ensure that the coverages you want or need are included and that they are accurately prepared. If you have one, your agent will also receive copies of your Information Page and any Endorsements. Please communicate with your agent or Berkley Administrators if there are errors or if changes are necessary. Also included for your review are the forms and instructions you need to report all workers' compensation claims to Berkley Administrators. ® Minnesota Workers' Compensation Renewal Document Please carefully review your renewal Policy or Agreement, the Information Page and any Endorsements to ensure that the coverages you want or need are included and that they are accurately prepared. ❑ New supply of First Report of Injury forms and/or the other information you requested. Mandatory Fraud Notice A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. Minnesota Statute 60A.955. You must maintain an adequate supply of First Report of Injury forms. They should be kept where they are accessible to the person who is responsible for completing the form and sending it to Berkley Administrators. If you have run out of forms or can't find your supply, please complete the form below and return it to Berkley Administrators. We will gladly send you a supply of forms and provide any other information you request. Please do it today because you never know when an injury might be reported by one of your employees. Please send the following information to the attention of: 02-000729 OAK PARK HEIGHTS PO BOX 2007 at the address at left. OAK PARK HEIGHTS, MN 55082-2007 ❑ First Report of Injury forms ❑ Supervisor's Report of Accident forms ❑ Minnesota Workers' Compensation booklet ❑ Employer's Injury Management Guide Clip and mail to: ❑ Hiring Practices and Disabilities booklet ❑ Employer's Loss Control booklet Berkley Administrators ❑ Deductible information PO Box 59143 Minneapolis, MN 55459-0143 BA 3110(10/96) Lele of Minnesota Cities Insure Trust Group Self-Insured Workers' Compensation Plan Workers' Compensation and Employers' Liability Agreement Administrator Berkley Administrators a member of the Berkley Risk Management Services Group P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 Information Page RENEWAL 1. The "City" Agreement No. 02-000729-11 OAK PARK HEIGHTS "City" is: XCity PO BOX 2007 Joint Powers Entity OAK PARK HEIGHT MN 55082-2007 Other (describe) 2. The Agreement period is from 12:01 a.m. 07/07/1997 to 12:01 a.m. 07/07/1998 at the "City's" address. 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers' Compensation Law of any state of the United States of America and the District of Columbia. B. Employers Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury-Each Claimant $200,000. Bodily Injury-Each Occurrence $600,000. Bodily Injury by Disease-Agreement Limit $600,000. C. This Agreement includes these amendments and schedules: 4. Retro-rating option selected? NOT APPLICABLE 5. Elected Officials Covered? YES Boards and Commissions Covered (List) NONE 6. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. PREMIUM BASIS ESTI- RATES ENTRIES IN THIS ITEM,EXCEPT AS SPECIFICALLY PROVIDED ESTIMATED MATED TOTAL PER $100 OF CODE ELSEWHERE IN THIS AGREEMENT; DO NOT MODIFY ANY OF THE ANNUAL ANNUAL REMUNERATION NO. OTHER PROVISIONS OF THIS AGREEMENT. PREMIUM REMUNERATION 86805. 4.62 5506 GENERAL MAINTENANCE 4010. 474844. 3.36 7720 POLICE 15955. 133710, 0.42 8810 CLERICAL 562. 62296. 2.62 9102 PARKS 1632, 54314. 1 .19 9410 MUNICIPAL EMPLOYEES 646. 20500. 0.45 9411 ELECTED OR APPOINTED OFFICIALS 92. Manual Premium 22897. Experience Modification 0.79 Standard Premium 18089. Managed Care Credit 0% 0. Deductible Credit 0% 0. AGENT F-411709883 0.00 Premium Discount 1243. LANDMARK INS SERVICE Discounted Standard Premium 16846. 232 S LK ST BOX 188 LMC Insurance Trust Discount 0% 0. FOREST LAKE,MN 55025 Net Deposit Premium 16846. BA 467CG (12/92) DATE 07/16/1997 • • • n .-1-1 League of Minnesota Cities Insurance Trust 3490 Lexington Avenue North St. Paul, MN 55126-2977 (612) 490-5600 Workers Compensation and Employers ' Liability IMPORTANT Report all workers' compensation injuries to the office of: Berkley Administrators a member of the Berkley Risk Management Services Group P.O. Box 59143 Minneapolis Minnesota 55459-0143 (612) 544-0311 Administered By: Berkley Administrators If an employee is injured: P.O. Box 59143 Minneapolis, MN 55459-0143 (1) Assist in obtaining medical attention if necessary. (2) Notify the office listed above. **IMPORTANT** PLEASE READ YOUR AGREEMENT BA 466 (8/92) In consideration of the depoIPf the premium with the ant to their ob ions,all acting through Berkley Adminis- League of Minnesota Cities Insurance Trust(herein LMCIT) trators,which is the Administrator named in the Information and in reliance upon the statements in the Information Page, Page made a part hereof,agrees with you,the City,named in and subject to all terms of this agreement and the LMCIT trust the Information Page as follows: document,LMCIT, acting on behalf of its members,pursu- GENERAL SECTION A. The Agreement C. Workers' Compensation Law This agreement includes at its effective date the Informa- Workers'Compensation law means the workers'compen- tion Page and all amendments and schedules listed there. It sation law and occupational disease law of the States named is an agreement of participation between you(the employer in item 3.A of the Information Page. It includes any named in item 1 of the Information Page)and us(LMCIT). amendments to that law which are in effect during the period The only agreements relating to this plan are stated in this of this agreement. It does not include the provisions of any agreement and the LMCIT Trust document. The terms of this law that provides non-occupational disability benefits. agreement may not be changed or waived except by amend- ment issued by us to be part of this agreement. D. Locations P B. Who is Covered This agreement covers all of your workplaces listed in items 1 or 5 of the Information Page; and it covers all other You are covered if you are the"City" named in item 1 of workplaces in any state unless you have other insurance for Cthe Information Page. "City" means the city or other such workplaces. governmental body, political subdivision, board or depart- ment or entity named in the Information Page. Unless E. Incidental Coverages specifically named in the Information Page, "City"shall not include a gas, electrical or steam utilities commission, port 1. Part One of this agreement applies to work performed authority, housing and redevelopment authority, or similar by you subject to the Longshoremen's and Harbor agency, board or commission, hospital or nursing home Workers' Act. board or commission,welfare or public relief agency, school board, or joint powers board. 2. Part Two of this agreement applies to work performed by you subject to the Federal Employer's Liability For purposes of Part Two-Employers'Liability Coverage Act. and for purposes of damages sought against them under Section 176.82 of the Minnesota workers'compensation law, 3. Part Two of this agreement applies to work performed the following are additional covered parties for actions by you subject to the Jones Act or U.S.Maritime Law. perfomed within the scope of their duties: A member of the city council;a member of any board or commission of the city This paragraph does not apply to bodily injury covered that is named in the Information Page;an elected or appointed under any other policy, agreement or plan issued to you. It official of the city;an employee of the city;a volunteer person does not apply even if the other policy, agreement or plan or organization while acting on behalf of the city; any other does not apply because of an other insurance clause, deduct- authorized person or agent of the city while acting on behalf ible or limitation of liability clause, or any similar clause. of the city,but excluding independent contractors;or a relief association and its officers, employees and members. PART ONE-WORKERS' COMPENSATION COVERAGE A. How This Coverage Applies The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by This workers' compensation coverage applies to bodily disease must occur during the period of this agreement. injury by accident or bodily injury by disease. Bodily injury includes resulting death. B. We Will Pay 1. Bodily injury by accident must occur during the period We will pay promptly from the assets of LMCIT, when of this agreement. due,the benefits required of you by the workers' compensa- tion law. 2. Bodily injury by disease must be caused or aggravated by the conditions of your employment. BA 466 (4/92) -1- C. We Will Defend • If we make any payme sin excess of the benefits regularly provided by the workers'compensation law on your behalf, We have the right and duty to defend, at LMCIT expense, you will reimburse us promptly. any claim, proceeding or suit against you and any other covered party for benefits payable under this agreement. We G. Recovery From Others have the right to investigate and settle these claims,proceed- ings or suits.We have no duty to defend a claim,proceeding We have your rights, and the rights of persons entitled to or suit that is not covered by this agreement. the benefits of this agreement, to recover our payments from anyone liable for the injury. You will do everything D. We Will Also Pay necessary to protect those rights for us and to help us enforce them. We will also pay from the assets of LMCIT these costs,in addition to other amounts payable under this agreement as H. Statutory Provisions part of any claim, proceeding or suit we defend: These statements apply where they are required by law. 1. reasonable expenses incurred at our request, but not loss of earnings; 1. As between an injured worker and us,we have notice of the injury when you have notice. 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amounts 2. Your default or your bankruptcy or insolvency will not payable under this agreement; relieve us of our duties under this agreement after an injury occurs. 3. litigation costs taxed against you; 3. We are directly and primarily liable to any person 4. interest on a judgment as required by law until we offer entitled to the benefits payable by this agreement. the amount due under this agreement, and Those persons may enforce our duties; so may an agency authorized by law. Enforcement may be 5. expenses we incur. against us or against you and us. E. Other Insurance 4. Jurisdiction over you is jurisdiction over us for purposes of the workers' compensation law. We are We will not pay more than our share of benefits and costs bound by decisions against you under the law,subject covered by this agreement and another insurance policy or to the provisions of this agreement that are not in self-insurance plan. Subject to any limits of liability that may conflict with that law. apply, all shares will be equal until the loss is paid. If any insurance policy or self-insurance plan is exhausted, the 5. This coverage conforms to the parts of the workers' shares of all remaining insurance policies or self-insurance compensation law that apply to: plans will be equal until the loss is paid. a. benefits payable by this agreement; F. Payments You Must Make b. special taxes, payments into security or other You are responsible for any payments in excess of the special funds, and assessments payable by us benefits regularly provided by the workers' compensation under that law. law including those required because: 6. Terms of this agreement that conflict with the workers' 1. of your serious and willful misconduct; compensation law are changed by this statement to conform to that law. ^� 2. you knowingly employ an employee in violation of law; Nothing in these paragraphs relieves you of your duties under this agreement. 3. you fail to comply with a health or safety law or regulation; or 4. you fail to comply with the reporting requirements of the workers' compensation law causing late payment of benefits to your employee and resulting in assessment of penalties. BA 466 (4/92) -2- ORT TWO-EMPLOYERS'LIABILITY CRAGE A. How This Coverage Applies C. Exclusions This employers'liability coverage applies to bodily injury This agreement does not cover: by accident or bodily injury by disease. Bodily injury includes resulting death. 1. liability assumed under a contract. This exclusion does not apply to a warranty that your work will be 1. The bodily injury must arise out of and in the course done in a workmanlike manner; of the injured employee's employment by you. 2. punitive or exemplary damages because of bodily 2. The employment must be necessary or incidental to injury to an employee employed in violation of law; your work. 3. bodily injury to an employee while employed in 3. Bodily injury by accident must occur during the period violation of law with your actual knowledge or the of this agreement. actual knowledge of any of your executive officers; 4. Bodily injury by disease must be caused or aggravated 4. any obligation imposed by a workers' compensation, by the conditions of your employment. The employee's occupational disease, unemployment compensation, last day of last exposure to the conditions causing or or disability benefits law, or any similar law; aggravating such bodily injury by disease must occur during the period of this agreement. 5. bodily injury intentionally caused or aggravated by you; 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by accident or by 6. bodily injury occurring outside the United States of disease must be brought in the United States of America, its territories or possessions, and Canada. America, its territories or possessions, or Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or B. We Will Pay Canada who is temporarily outside these countries; We will pay from the assets of LMCIT all sums you legally 7. damages arising out of the discharge of, coercion of, must pay as damages because of bodily injury to your or discrimination against any employee in violation of employees, provided the bodily injury is covered by this law. Employers' Liability coverage. D. We Will Defend The damages we will pay, where recovery is permitted by law, include damages: We have the right and duty to defend, at LMCIT expense, any claim, proceeding or suit against you for damages 1. for which you are liable to a third party by reason of payable under this agreement. We have the right to investi- a claim or suit against you by that third party to recover gate and settle these claims,proceedings and suits. We have the damages claimed against such third party as a result no duty to defend a claim, proceeding or suit that is not of injury to your employee; covered by this agreement. We have no duty to defend or continue defending after we have paid our applicable limit of 2. for care and loss of services; and liability under this agreement. 3. for consequential bodily injury to a spouse, child, E. We Will Also Pay parent, brother or sister of the injured employee; We will also pay these costs, in addition to other amounts provided that these damages are the direct payable under this agreement as part of any claim, proceed- consequence of bodily injury that arises out of and in ing, or suit we defend: the course of the injured employee's employment by you; and 1. reasonable expenses incurred at our request; but not loss of earnings; 4. because of bodily injury to your employee that arises out of and in the course of employment; claimed 2. premiums for bonds to release attachments and for against you in a capacity other than as employer. appeal bonds in bond amounts up to the limit of our liability under this agreement; BA 466 (4/92) -3- 3. litigation costs taxed against yill pay for all dam covered by this agreement because of bodily injury by accident or disease to one or more 4. interest on a judgment as required by law until we offer employees in any one accident, regardless of the the amount due under this agreement; number of claimants. 5. expenses we incur. 3. Bodily Injury by Disease - Agreement Limit. The limit shown for "bodily injury by disease-agreement F. Other Insurance limit"is the most we will pay for all damages covered by this agreement and arising out of bodily injury by If any claim against you is also covered by another disease, regardless of the number of employees who insurance policy or self-insurance plan,we will pay only for sustain bodily injury by disease,and regardless of the our proportionate share of the loss. Our proportionate share number of claimants. will be determined by applying the ratio that the limit of liability provided by this agreement bears to the total of all Bodily injury by disease does not include disease that limits of liability provided by all policies or plans in effect to results directly from a bodily injury by accident. the total amount payable for the loss. The limits of liability and amount payable under this agreement and any other 4. We will not pay any claims for damages after we have policy or plan shall be calculated as if each plan or policy were paid the applicable limit of our liability under this the only one applicable. The limits of liability and amount agreement. payable under any other policy or self-insurance plan in effect shall be included in the calculation, regardless of whether it H. Recovery From Others is described as primary,excess,contributory,contingent,or otherwise,unless that policy or plan is specifically described We have your rights to recover our payment from anyone as providing coverage in excess of the limits of this agree- liable for any injury covered by this agreement. You will do ment. everything necessary to protect those rights for us and to help us enforce them. G. Limits of Liability I. Actions Against Us Our liability to pay for damages is limited. Our limits of liability are shown in item 3.B. of the Information Page. There will be no right of action against us under this They apply as explained below: agreement unless: 1. Bodily Injury-Each Claimant. The limit shown for 1. You have complied with all the terms of this "bodily injury-each claimant"is the most we will pay agreement; and to any one claimant for all damages covered by this agreement because of bodily injury by accident or 2. The amount you owe has been determined with our disease to one or more employees in any one accident. consent or by actual trial and final judgment. 2. Bodily Injury-Each Occurrence. The limit shown for This agreement does not give anyone the right to add us as "bodily injury-each occurrence"is the most we will a defendant in an action against you to determine your liability. PART THREE-YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this 4. Cooperate with us and assist us,as we may request,in agreement. Your other duties are listed here: the investigation, settlement or defense of any claim, proceeding or suit. 1. Provide for immediate medical and other services required by the workers' compensation law. 5. Do nothing after an injury occurs that would interfere with our right to recover from others. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other 6. Do not voluntarily make payments, assume information we may need. obligations or incur expenses,except at your own cost. 3. Promptly give us all notices, demands, and legal papers related to the injury,claim,proceeding or suit. BA 466 (4/92) -4- 411 • PART FOUR-PREMIUM A. Our Manuals E. Final Premium All premiums for this agreement will be determined by our The premium shown on the Information Page, schedules, manuals of rules, rates,rating plans and classifications. We and amendments is an estimate. The fmal premium will be may change our manuals and apply the changes to this determined after this agreement ends by using the actual,not agreement. the estimated, premium basis and the proper classifications and rates that lawfully apply to the business and work covered B. Classifications by this agreement. If the fmal premium is more than the premium you paid to us, you must pay us the balance. If it Item 5 of the Information Page shows the rate and premium is less,we will refund the balance to you. The final premium basis for certain business or work classifications. These will not be less than the highest minimum premium for the classifications were assigned based on an estimate of the classifications covered by this agreement. If this agreement exposures you would have during the period of this agree- is cancelled,final premium will be determined in the follow- ment. If your actual exposures are not properly described by ing way unless our manuals provide otherwise. those classifications, we will assign proper classifications, rates and premium basis by amendment to this agreement. 1. If we cancel, final premium will be calculated pro rata based on the time this agreement was in force. Final C. Remuneration premium will not be less than the pro rata share of the minimum premium. Premium for each work classification is determined by multiplying a rate times a premium basis. Remuneration is 2. If you cancel, final premium will be more than pro the most common premium basis. This premium basis rata. It will be based on the time this agreement was includes payroll and all other remuneration paid or payable in force, and increased by our short rate cancellation during the period of this agreement for the services of: table and procedure. Final premium will not be less than the minimum premium. 1. all your officers and employees engaged in work covered by this agreement; and F. Records 2. all other persons engaged in work that could make us You will keep records of information needed to compute liable under Part One (Workers' Compensation premium. You will provide us with copies of those records Coverage) of this agreement. If you do not have when we ask for them. payroll records for these persons,the contract price for their services and materials may be used as the G. Audit premium basis. This paragraph 2 will not apply if you give us proof that the employers of these persons You will let us examine and audit all your records that relate lawfully secured their workers' compensation to this agreement. These records include ledgers,journals, obligations. registers, vouchers, contracts, tax reports, payroll and dis- bursement records, and programs for storing and retrieving D. Premium Payments data. We may conduct the audits during regular business hours during the period of this agreement and within three You will pay all premium when due. You will pay the years after this agreement ends. Information developed by premium even if part or all of a workers' compensation law audit will be used to determine final premium. is not valid. PART FIVE-CONDITIONS A. Duty to Indemnify 4. For which the "city is not authorized to indemnify any person by statute; or Our duty to pay on behalf of or to indemnify a"covered party" other than the "city" shall not apply to any act, 5. Which constitutes dishonesty on the part of a error or omission: "covered party"; or 1. Which constitutes malfeasance in office; or 6. Which constitutes the willful violation of a statute or ordinance by any official,employee or agent of the 2. Which constitutes willful neglect or duty; or "city". 3. Which constitutes bad faith; or BA 466 (4/92) -5- The terms"malfeasance", "willful neg of duty",and"bad Mailing the no to you at your mailing address faith" shall be given the same meaning in this agreement as shown in item 1 of the Information Page will be given in the applicable statute with respect to the"city's"duty sufficient to prove notice. to defend or indemnify its officials, employees or agents. 3. The period of this agreement will end on the day and B. Inspection hour stated in the cancellation notice. We have the right, but are not obliged to inspect your 4. Any of these provisions that conflicts with a law that workplaces at any time. Our inspections are not safety controls the cancellation of the coverage in this inspections. They relate only to coverage and the premiums agreement is changed by this statement to comply with to be charged. We may also recommend changes. While they that law. may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your F. Assessability employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with All"cities"who participate in this program are jointly and laws, regulations, codes or standards. severally liable for all claims and expenses of the program. The amount of any liabilities in excess of assets may be C. Long Term Agreement assessed to the participants when a deficiency is identified. If the period of this agreement is longer than one year and G. Sole Representative sixteen days, all provisions of this agreement will apply as though a new agreement were issued on each annual anniver- The City first named in item 1 of the Information Page will sary that this agreement is in force. act on behalf of all covered entities to change this agreement, receive return premium,and give or receive notice of cancel- D. Transfer of Your Rights and Duties lation. Your rights or duties under this agreement may not be IN WITNESS WHEREOF, the City agrees to look solely transferred without our written consent. to the League of Minnesota Cities Insurance Trust for reimbursement of all losses,costs and expenses arising under E. Cancellation this agreement;and further agrees that in no event shall claim be made or asserted against the revenues or property,real or 1. You may cancel this agreement. You must mail or personal,of the League of Minnesota Cities. Acceptance of deliver advance written notice to us stating when the this agreement by the City constitutes acceptance of all terms cancellation is to take effect. hereof. 2. We may cancel this agreement. We must mail or League o • n- to ities Insurance Trust deliver to you not less than ten days in advance written /��I notice stating when the cancellation is to take effect. By: Its ut I s ri ed epresentative BA 466 (4/92) -6- 411 • A• N AAm o H M UmO HO • N 00 0 m 0 H N RC H 4 M 0 N h H U CO a1 N CO ■r'1 0 I ei MO N.1 0 P'0 a'a • o Mo OW CO 0 mw A M N H g N , . a a 0 M o M CzA o E4 Wo 0ti00 0 Sao .16.;..; M as r$ E M W M gm H OH OZO Wp0 0.1 O COEO+ZO • A m H ocw 4H HOO O ■4 OH • • • NN O0 SEC ■ M a '�g O H° H H 0 00 E at 000 U'.l \O h HO00 O h Mal 4H00 IA ZA ■HOm a M N O N4Am N ON OM \. H0 p° N O QOH NW HHHo F 4H HAO EOA CO v'H a iI Ao CO M�A• a a aogx 1 N"'°a uH So o 0 OZ I U�A-1MN A cgnpoz ••CgRµi0 a UU HH CA 4 M �• I p * z MM OH q O H MUM �aO0 HU HO CO WMMU a.4 404 A a a a CO g O H COO l.4 CO S o0 as uu C4 CO >+ 1 CO aZ g OZri HO a H M ON 1°a a uo .7 Ou El g(ry 0 CAM Hm 1F7 xw . NE CO IIIL m • MID• H UZH w gun) illkLeague of Minnesota Cities Insuranc st roup Self-Insured Workers' Com ensa Plan P P Workers' Compensation and Employers' Liability Agreement Administrator Berkley Administrators P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 STATEMENT OF PREMIUM AUDIT ADJUSTMENT The "City" Agreement No. 02-000729-10 OAK PARK HEIGHTS Agreement Period: From 07/07/1996 To 07/07/1997 PO BOX 2007 OAK PARK HEIGHT MN 55082-2007 Rates Audited Annual Per S100 Of Code Audited Remuneration Remuneration No. Classification Premium 47573. 4.86 5506 STREET CONSTRUCTION & MAINTENANCE 2312. 442345. 3.53 7720 POLICE 15615. 169999. 0.44 8810 CLERICAL 748. 93560. 2.76 9102 PARKS 2582. 51774. 1.25 9410 MUNICIPAL EMPLOYEES 647. 18200. 0.47 9411 ELECTED OR APPOINTED OFFICIALS 86. 823451. Manual Premium 21990. Experience Modification 0.81 Standard Premium 17812. Managed Care Credit 07. 0. Deductible Credit 0% 0. Premium Discount X1217.:= Discounted Standard Premium 16595. LMC Insurance Trust Discount 07.. 0. Net Actual Premium 16595. Less Deposit Premium 17608.00 Balance Due City 1013.00 The foregoing statement is for the year end adjustment to your workers' compensation desposit premium. It was prepared after an audit of your payroll records and a final determination of your experience modification factor for the period indicated above. If the final balance shown is due to your city, a check will accompnay this form. If the final balance shown is due to the LMCIT, please forward your remittance, payable to the LMC Insurance Trust,to the adminsitrator at the address indicated above. Agent F-411709883 0.00 LANDMARK INS SERVICE 232 S LK ST BOX 188 FOREST LAKE,MN 55025 BA 446CG (5/91) Date: M. SE0 03' 91 • • LMC 145 University Avenue West, St. Paul, MN 55103-2044 League of Minnesota Cities Phone: (612) 281-1200 • (800) 925-1122 Cities promoti g excellence Fax: (612) 281-1299 • TDD (612) 281-1290 To: Agents and City Officials From: Pete Tritz Re: New Address and Phone Number for Workers Compensation Claims On September 8, 1997 Berkley Administrators will be moving their key LMCIT work comp staff into the League of Cities offices in St. Paul. Beginning then, all communications and reports on member workers compensation claims should be directed to LMCIT, Workers Compensation Claims, 145 University Avenue West, St. Paul, MN 55103-2044. To report new claims: The new Fax First numbers for submitting a First Report of Injury by Fax are Greater Minnesota - 1-888-234-7839 or Metro area - 215-4185 The new direct dial telephone numbers for key Berkley Claims staff handlers are as follows: Bruce Franzen General Manager (612) 215-4170 Patty Prentice Examiner (612) 215-4171 Keith Rear Examiner (612) 215-4172 Shannon Schneider Examiner (612) 215-4174 Tara Draves Claim Services Technician (612) 215-4176 Christine Jesperson Examiner (612) 215-4177 Melissa Sanders Claim Services Technician (612) 215-4178 r- Renee Sakry Examiner (612) 215-4179 �' —�-- Barb Longnecke (612) 5 18 I Examiner vim Lim-�rio0 �7E1" .- 41997 11 ,• Kim Hruby Claim Services Technician (612) 215-4181 1 9 Quotes and renewals { Requests for new or renewal quotes should be directed to Barb Meyer at the League offices. Barb's new direct line phone is (612) 215-4173. We think this move will help us better serve you,through improved communication and simplified claims reporting. The move two years ago of Berkley Risk Services' Property and Casualty claims, underwriting and loss control personnel has been a significant success and we hope to see similar results in the workers compensation program. AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER Berkley ld i r Adm nest ato rs PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN 55426 Phone (612) 544-0311 • Fax (612) 591-7404 August 20,1997 `. . 1 ( Y I City of Oak Park Heights LLUYO[ JPO Box 2007 K PARK HTS Oak Park Heights, MN 55082-2007 Dear Judy, Here are the audit worksheets per your request. Thanks, Barbara Meyer Policy Service Tech Member of the W.R. Berkley Group Go Berkley /ninistrators • PO Box 59143,M P Is., MN 55459-0143 • Phone (612)544-0311 • Fax(612)591-7404 pw �� x CLIENT F INSURED �'� x E � W, "1,'o_� �� ,�. .., ' . . . .. __.. CITY OF OAK PARK HEIGHTS #135 PO BOX 2007 Berkley Administrators OAK PARK HEIGHTS,MN 55082-2007 AUDITOR NAME : ' `r.. ;: " AY': " r 4 HEATHER SCHLEY POLICY NUMBER:: ' POLICY PERIOD:`." ,'AUDIT PERIOD £,', * ' 'FILE ID: 02-729 07/07/96 To 07/07/97 07/01/96 To 07/01/97 AA9 08/12/97 Page 1 of 6 SUMMARY PAGE KEY= A-AREA B-FRONTAGE C-REMUNERATION D-SALES/RECEIPTS E-COST F-ADMISSIONS -G.PER CAPITA/EACH K S CLASSIFICATION E r r0DES BASIS REMIUM A PREMIUM Y E E WorLLrs Compensation Summary STREETS&MAIN TNENANCE C MN 5506 47,573 POLICE OFFICERS&D C MN 7720 442,345 CLERICAL OFFICE EMPLOYEES&NOC C MN 8810 169,999 PARK NOC-ALL EMPLOYEES&D C MN 9102 93,560 BUILDING INSPECTOR C MN 9410 51,774 ELECTED OFFICIALS: MAYOR&COUNCIL C MN 9411 18.200 823,451 General Liability Summary LESS AMOUNT PREVIOUSLY BILLED EARNED PREMIUM LESS PREVIOUS BILLING LESS DEPOSIT PREMIUM IJAP OR (I RP DIVIDEND BALANCE DUE [I INSURED(j COMPANY Berkley AAninistrators PO Box 59143,Mpls., MN 55459-0143 • Phone (612)544-0311 • Fax(612)591-7404 nt 1NSURED, �:�� w� *� �r� � ... CL1EN_T_ " �.�.. ES �. CITY OF OAK PARK HEIGHTS �. �� �� #135 PO BOX 2007 Berkley Administrators OAK PARK HEIGHTS,MN 55082-2007 AUDITOR NAME. r. , HEATHER SCHLEY POLICY NUMBER, ";s"„POLICY PERIOD +; t'`A,UDIT PERIOD s ' FILE ID ' DATE: 02-729 07/07/96 To 07/07/97 07/01/96 To 07/01/97 AA9 08/12/97 Page 2 of 6 Description of operations--Provide detailed description of all operations/services. Include all locations,products or services,distribution or delivery methods,and materials handled etc. List all officers partners or Owners-Their duties, remuneration and class codes. Corporation E Individual Closely Held Corporation El Partnership Other Limited Liability Corporation N a n Audit Notes Key Questions Y N e 1. Premium overtime excluded?If no explain. 2. Are relatives employed?If yes list on audit 3. Did the condition or type of records cause additional audit time? 4. Is there a'125"Cafe Plan or 401K Plan? 5. Board or Lodging provided? 6. Are commissions or bonuses paid? Audit Records: use Policyholder Terminology 7. Did the insured request a division of any employees payroll? 8. If yes to 7 did records reflect proper division? 9. Casual or contract labor? 10. Aircraft operation? 11. Any sub-contractors used? 12. Are certificates on file for all subs?(if no provide complete details) 13. All classifications of policy accounted for! 'r Next Audit: 14. Was an owner or officer interviewed? Federal Tax ID#: State Unemployment Account#: 0 0 m m _i «. « « �. 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H vHt' • ac 1i1 w oyH onion m - r/� vi 'j r H a X Y Berkley • Administrators PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN 55426 Phone (612) 544-0311 • Fax (612) 591-7404 LP, t I eil �{ I;i JUN I 61997 June 12, 1997 111\\I Dear Client, Berkley Administrators is committed to providing you with quality products and excellent customer service. To enhance our services to you, we are considering plans to offer increased customer service through the internet, including e-mail to Berkley employees, on-line first report of injury reporting,electronic agent submissions, and educational return-to-work and loss control programs among other things. We want to provide you with internet tools that will make your job easier and more convenient, while ensuring the highest level of security. To help us design an internet presence that meets your needs, please complete the enclosed survey and return it in the postage-paid envelope by June 30. The information you provide will be kept strictly confidential and will only be used to help us determine how to best serve your needs. We value your ideas and opinions. Thank you in advance for taking the time to complete this important survey. If you do have any questions, please feel free to call or e-mail me. Sincerely, Randy Hedman Sales/Marketing (612) 525-5705 rhedman@wrbc.com Member of the W.R. Berkley Group • Berkley Administrators PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN 55426 Phone (6121 544-0311 • Fax (6121 §91-7404 Internet Technology Client Survey 1. Currently, my company/organization is : (Check the one which applies to your company) Connected to the Internet and the World Wide Web Connected to the Internet with e-mail only capabilities Other type of Internet capabilities (Please specify:) Not connected to the Internet(Please answer the following questions) a. We expect to be connected: 1 b. We currently have a PC in less than 6 months in 1 -2 years ' with a modem: in 6- 12 months never Yes No 2. If your organization currently has access to the Internet/World Wide Web, how do you use it for business purposes? 3. Would you like to use Internet technology in your interactions with Berkley Administrators? Yes No If yes, how would you like to use it? : (Please check all that apply) Communicate via e-mail with Berkley Administrators' staff: Claims Loss Control Auditors Policy/underwriting Management Marketing Computer Other View/download my company's loss run Access general safety and loss control information Access claim payments by claim number Access claim handler's file notes Complete/submit Injury Reports on-line Access educational claims management information Access policy information (premium payments, experience mod, etc.) Access other claim information (Please specify:) Complete and submit applications for coverage on-line Access information about other services provided by Berkley 4. Additional comments, suggestions, ideas: 5. The person completing this survey is: Name c--)u.c . (-Ea ( s f Phone Number 6/.P-41,39'- 9 Title /ewf /I rk/ f./14e c d',t ctvr 6. Your organization's approximate annual workers' compensation/premium is : Less than $10,000 )< $10,000 to $49,999 $50,000 to $100,000 over$100,000 Thanks for your assistance! P02 Member of the W.R. Berkley Group III • 0▪0 0. Y 0 II y�0 oa VH ow H CI no w001)' m yam lie PO PS !I MM * 00 WW H . . no MY NN aM W WV 0)' ae I aax •a AO O HH xoae ate V.K W A N N O 00 $ tin W oM We H H M H 0 H MV C))' )' 01 OH HMH n 70 H '{Uq 1WM HOyHW H07W MMZ *MOW Q iZ�CC i V000 F4 fl o t"tn+ CH 0 � m o n a O n o 14 VO 14 )' NO40 PI OH'U N to w 00 V ''a Z - L..rd b Oo' C N 00 0 rr0 1414 - 0 ° ,� 00 w0 r-4X rNti -J 0 ti� Nx Ac-, C 0 0y M114o �-'d •••• 03MY 101001 3 ') yn H 0101 0`� m° W 000+0 46-. Kn Ei l0 r a v-1 .N1� H M> burr! MM 0-10 0 M � L:°� H bull; L. 0 m M O O Hy MO )'` 0 00. N Om x�'rs ooZHO-3 to 00m0 HO H oM N H 0014)' X 00MW0 0014 H 0001 W 0 V W F. b o m a 0 NH o M 0 0 MO 0 O14Q H 0 4V 00W O O N 01 ■ 0 H rr ■ oM 10 uo H v ea 42.10140 N III H OooHV 0p r1 00 o o Ht+ NWHr I • • V1-3 r:. 5 H �.+ 411 .4. . .0.1 L9 LG L1 W W H MI rn * °x H X00 MP M 00 L+1 WV OP rot, ZH roz L1 r C M oIZ HO oM 0 H [r+,G 00 Z 00 M N x oDt zn 0-3 0 VI '•d 'il y W H .h7 R7 0.79 hl 7C H H OH LH HyOHt•] HHHZtt, to 00 *m00 m H 1 0 I - H OC •• ry H 00 0 MM e a OOOM try 04 0 00 % Zr) ' O0° M• VM W HP tgl Li 0 ern Z ti 00 V H P H ✓ o.ti '0GK VP H r y N C n %• Pi 0 H - 00 roo N NW ONOH\ rz NJt,ro - VI L4O H NJH'yi 0441 - CI • OH O, o\ K o• ot+ a L1t1 --1• 1)3 H to vC 0 H H CO0 0 HM OO H▪ t1 H �\ b 00H r Hr NV 004 N t,to Z W HH t0 L+1 .• 00 t4 0M0 F4O H in L+1 L+1 >4 H tn ro ro M O O Z H b 0 ooMU OM P ooL9 • 0 H OW CS1 ON S 0 _l 'il d to L0+1 ro N Sn2 N �H • H X. w" O [+U m0 G= o H F7').- W \ ce, 11 ton H V � 0OH tIrwu 0 H to H o r 411 0 CO °Fl 0 v O Ht" e2C 0$ III 411 ,... o rHH � n y N)t o N 110 W(I im , H N CO no .Hy rWt� Q0 O Iv 11:14 . 11 oWE xn NH O H b.4 NH HORN H onnt+ H oh0•• 0 o G W V m pc t4 n OS V N• VW Z ROM W )0N H Wgv Wokw W o wx W• ow O H OW ✓ oH0 NO4 VO III .„ • "H o • gg ■r G o b O w0-4 0 NNW mOH■ VW Na0k1 ■WW0 H NdH,b tOW -1 n N OD p u m .il r '4o 00 l m r g m H • G •40 O $H 0o v O gm .15 o ww y o xW 00 4 I', OW W I 1.4H t0 W 0 PC• 00 �ro OW N O H ppgg W m DS GA H 0oCrag 6X 00NA0 • Z H 1 [ , a om O 1 o Nr � NH wN N H loh x o .. m, o s WJ U H 4• 0' � / t H y tn H o t4 a i • C)H C)LO o V H — o H e APPROVED OMB NO.0938-0279 2 ° A 3 PATIENT CONTROL NO. 4 TYPE I_fdKE.V)�-I. I,;,I 11t)`:i1'.C1�r�1 OF BILL (1 130X 1 42 zdl ;t➢ .I41r�C�!� 1, ,?f>i;3 1=s1 M:1:Id N E fl I L:G` I, 6 STA- NT COVERS PERIOD T.`�� 1 .N { 5 FED.TAX N0. rROM THROUGH 41/1/ D. 8 N-C D 9 CID 10 L-R D. 11 61. 4? .A ; . ' i t0 41 4h 4.h G9 0 €'i 12 PATIENT NAME 13 PATIENT ADDRESS A N D E R`;C1 f'•d '6_F:N N k: 1"F1 P [i h 1 ',1 i MI!s 1'A P h- P N ;; 3 I i_E 1,i A T L I MN ' '' 13 ('? ADMISSION 14 CODES 14BIRTHDATE 15 SEX 16 MS 17 DATE 18HR ;19TYPE,20 SAC,21DHR22STAT23 MEDICAL RECORD NO. 24 _ 26 28 aaa � Bo 31 M M �I u' > (�l I .1 c, 1 / 41 116"11 32 °ccLIRRENGE 34 OCCURRENCE 36 OCCURRENCE SPAN 37 caDE ;DATA ' - CODE DATE �: c©DE FROM THRO�cH A A 'a B B b C f 39 VALUE CODES Y' s 41 > VALUE CODES 38 ?� ( (._�' O Q+� F [ I'���, 1 IT fi CODE AMOUNT GODS ;.AMOUNT 1 ±`4'08 DI% t:V7, NI:; r1 F f'4I;'4[I a a b b 1'I I I i' V11\1 _ d d 42 REV.CD. 43 DESCRIPTION 44 HCPCS I RATES 45 SERV.DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 1 4['DO E`r'(I Nt'l 41,1(..)471 ?`;)<' r>6'1 rt ') 1 2 540 Ah11N1,II_ NCF' 4 115 } 80 2 3 ON 1 1,1, 1) I [ 1 /4:4 v 1 � � 3 4 4 5 5 6 6 7 7 8 8 9 9 10 \V {-1q, 10 11 11 12 12 13 1 13 14 14 15 15 1s CITY OF 16 17 OAK PARK HEIGHTS 17 18 18 19 19 20 20 21 21 22 22 23 0 0 1. 1 0 1 4 1 1 1-1:11 j'?1'11 0 i, 1. ',)0 23 50 PAYER 51 PROVIDER NO. S3" 8.'.54 PRIOR PAYMENTS 55 EST.AMOUNT DUE 56 INFO NEN A 1;110PF'. I,c CC!M41 B P F PF F"E1 ONFF" 8¢ C 57 DUE FROM PATIENT 58 INSURED'S NAME 59 P.REL 60 CERT.-SSN-HIC.-ID NO 61 GROUP NAME 62 INSURANCE GROUP NO. A ANn1 p`ii1N F f, NNL. I H N G4 1 (I / , 1f'1(1'-; A B A INN11)E:R SON 4<E:"N N'E°'I 1-1 P T. B C C 63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION A 1 1:;a' 4 Al2< [44 1.(,I', I), 3,A4< 1,A1.'K H MN 4,r.148 A B 1 °A:1 PARK P0IW.T,CE B C C OTHER DIAG,CODES 67 PRIN.DIAG.CD. 68 CODE ,s.= - 70 CODE 4r k. 4 i 72 CODE b'"='- 74 CODE`; 76 ADM.DIAG.CD. 77 E-CODE 78 �7?41 i X11 / 80 PRINCIPAL PROCEDURE 81 i OTHER PROCEDURE 79 P.C. CPODE DATE CODE DATE „Tg; 82 ATTENDING PHYS ID f'I Ii I. r -) a P t I [ 1 41'11.41A t� ' b MT ER P'4CEDU'E OTHER PROCEDURE 83 OTHER PHYS,ID N N 6 a r',.Z`+ CODE DATE H...-- a��1 .�s.�S.�_ CODE �, DATE 1-4 ),'4") , MTCI.1laI" I.. b a 84 REMARKS OTHER PHYS.ID a x , A1 k.ot_./ 12t1V6 b b 86 psotvi3.5.,i R SENTATIVE SE DATE UB-92 HCFA-1 450 COPY 2 I CERTIFY THE CERTIFICATIONS ON THE RE -SE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. Minnesota Department of Labor and Industry Workers'Compensation Division First Report of Injury 443 Paul,MN Read North S tructions in folder accompanying forms. I.o 11111111 I 11111 1111111 I"I St:Pwl,MN 66166.306 (812)298-2432 A tes must be entered in'MM/DD/YY format. Type or Print. EMPLOYEE 2.Name past,first,middle) 3. EMPLOYEE SOCIAL SECURITY NO: t _ 9�Ru+ k e As. mm Allen I- 77 `5 ©t"S �' r 4. Home address(include county and rzi Ii 5.DATE OF CLAIMED INJURY: r ��), S C �iZile-11 " ' 4 4 'e- /A Jl 14 10114 Do Not Use this Specs ch P12191 121 C Y04 I -, `j J tt'' �� 6.Sax: Male Female 7, Marital Status: XMarried Not 8. Occupation: , 9.Date of Birth: t 1 Ifs/ 7 / 9 Q 10.Date Hired: (® I%/ 7 - �u i I Icy' , i 5,,ocf,rt 1 1.Regular Dept,......„' 12. Home Phone No. (A/C,No.) %A. S P>�C if n el Iota-9 3 V_ Q�e� 13.Apprentice: �No _Yes WAGE INFORMA ON ,/ 15.Rate per hour 7 16.Hours per day: 14.Average wage/week 77 f fO i"/9-i-e- 17.Days per week: 5- 18.What is the weekly value of MEALS: $ LODGING: S 2nd INCOME: I 19.Employment Status: XFuII time _Part time _Seasonal _Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No_ OCCURRENCE 20. PLACE(include dept&full address) 21.Data of first w 22.Date employer 7 C.,1 +, 04' ©A k �7��k E+a J,f-S day of lost time: _/_/ notified of injury: / /�.0 1 g i tog 1, S 7 h 01 24.Data employer notified ,V 23.Return to work date: 0 Be,x �y.o -ii ss0?2, of lost time: _/_/_ f1,1 A O W kt' A a. . . f '�/',�,, ---�`- 26.Time of day AM go')I�l�1 rLe a TT r C�, 25.Date of death: of of injury employer's premises Yes f No ,"d o ) 0 PM 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL.BE SPECF IC(include penis)of dy affected,e.p.amputation of right index finger a joint.fractured arm,lead poisoning) try c Pr4i , 1•,. ,S, ,itC , a //v (..t., :t � e.5( ssf.if/ h4r-sn 4/n 5 /41 v �F4 Lr .S4 e9ei/ 47.er# tor 1- - €-" t`' i07 /€'r/ 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of tfvar individuals involved,toots.machinery.obje�cts v�ore, ' chemicals,radiations unnatural motion of amployee •� r ..2-.0..7 �.Ti9� �4 f �/ e s'„ _� w� �E' i7� '�1 sue-/"v, 7 . /,�/®Ec,P �� �'ie.� 4' �,� 7-e' " 29. YSICIAN (full nor 1-' ' le, address and phone number) 30.HOSPITAL/CLINIC (name and address) 31.Witness and phone number. EMPLOYER 32.Legal name&mailing address incl.zip 34.Unemploy ID No OAK PARK HEIGHTS 33.Data form completed: 7/2‘,21.V ,.---- 14168 57TH STREET, BOX 2007 STILLWATER MN 55042 35.SIC code Payroll Class Code 36. Print supervisor's name and phone nuX39-5/5/2 m ber 37.Employer's Representative,print full name,tide and phone number. ,�r1 Uo n n e C(J;/se-,, 9 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF INSURED 41.Insurance Class Cade: MpIs Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Date insurer received notice: 42.CARRIER CLAIM NUMBER C12-0010729 44.Adjuster ID No: 0698639002 • L1-20320.06(1-92) Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division I _- T_ ��T BX HOSP 1874H AKE V IE V V 927 West Church et MEDICARE 24-0066 PATIENT BILL (L Stillwater,MN IRS 41-0611697 � DPW 0101712 HOSPITAL (612)439-5330 Fax(612)430-4660 � "' KENNETH R ANDERSON KENNETH R ANDERSON 416914150EC960 Outpatient $ PATIENT NAME I RESPONSIBLE PARTY MED.RECORD NO. TYPE AMOUNT REMITTED PLEASE DETACH AND RETURN THIS STUB WITH YOUR REMITTANCE TO INSURE PROPER CREDIT. KENNETH R *VERSION 41691415DEC960 11FEB1966 1 PATIENT NAME MEDICAL RECORD NUMBER € BIRTHRATE PAGE NUMBER POLICYHOLDER NAME/ADDRESS INSURANCE INFORMATION KENNETH R ANDERSON Primary: WORKERS COMP 1506 DRIVING PARK ROAD Id ND 470961003 Gr No STILLWATER, MN 55082 Secondary: PREFERRED ONE Id No Gr No Tertiary: December 19, 1996 December 15, 1996 December 15, 1996 POTTER MICHAEL BILLING DATE ADMITTANCE DATE DISCHARGE DATE PHYSICIAN 1 DATE SERVICE CODE DESCRIPTION QUANTITY UNIT PRICE AMOUNT CHARGES 15DEC96 2703173 99282 LEVEL II EMERGENCY ROOM 1 $60.80 $60.80 15DEC96 2711282 99282. LEVEL II PHYSICIAN 1 $78.30 $78.30 15DEC96 3201000 ALS MINOR 1. $436.70 $436.70 15DEC96 3203000 LOADED MILEAGE 2 ••.20 $16.40 15DEC96 3205015 PULSE OXIMETER 1 $22.70 $22.70 SLN ARY OF CHARGES/PAYMENTS AMBULANCE $475.80 EMERGENCY ROOM $60.80 PHYSICIANS $78.30 Total Charges $614.90 TOTAL OF CHARGES/PAYMENTS $614.90 THIS IS A COPY OF A BILL WHICH HAS BEEN SUBMITTED TO THE ABOVE INSURANCE ON YOUR BEHALF, IF THE INSURANCE CARRIER DOES NOT MAKE PAYMENT WITHIN 30 DAYS FROM THE BILLING DATE, THE BALANCE WILL BE YOUR RESPONSIBILITY. Vr_ TOTAL » $614.90 LAKE V IE Y V 927 West Churchill Street HOSPITAL 39-5 ater,MN 55082 (612)439 5 3 330 Fax(612)430-4660 I t'LW .Aar I � as T ' a RUN NO 4 a t o ` a x " A )� t� �a '' • � RESP CODE TRAN COOS a e [ s r ' ° RE '' DING FROM SCENE LOCATION CITY " ° n d TT' I -D W ATT NOANTilD A fi � � P 111 FIRST RESPONDER a x T� 2 ` m e; �...-.;:. TI ME MOTOR RESPONSE VERBAL RESPONSE EYE OPENING r '- ' CALLED--"''''111�®�'�� SPONTANEOUS � % 'a OBEYS COMMAND d ORIENTED g ,, z EN sL ®��� TO VOICE 3 ROUTE PURPOSEfULMVMT 5 CONFUSED r s° ',';. . 1 I a INAPP WORDS © TO PAIN , `* ARR. ���� WITHDRAW PAIN SCENE �'v a �.,.� *�. .`. FLEXION IPAINI 3 INCOMPREHENS © NONE MED.CONTROLM MRC ORBN LV �' �& M RCL 1J� - SCENE 0 -- EXTENSION(PAINT 2 NONE DO.B. /1 y/y SEX WEIGHT ARR. 'Z NONE I ilk- AG ���D /` HOSP � - C EF OMPLAINT n , n IN ODOMETER �� 1I{� TIME BP PULSE RESP Sa02% ' A„ f I'� t l Jr Jl>t aGJ.� j , 1 G� 1``�'�. SERV. S A?ART :k17 Q a d ��� ,O� Q/l(f SCENE / Ip HIST�RYOF PRESENT ILLNESWINJURY , AT HOSPITAL ''ti cat p = DESTINATION �I ,LOADED I,.�t t & c h i MILEAGE V 1 CJY�i Yltl h'\ `1k�t�v��1 f k 5l � � �� '1C�.9 iro �� 0-11 cJ bak c:10,4:,,,,,1° M} low �r.pvinc�Ot�.taL� . 1�e cU Ir� ( S2A1PSto CA-, — ( \DIU(1 v,soar. . Rw.btkk y I� ��tnu v► S Q!✓�� U�� /AIRWAY MEDIC II TIME ATMPTS 02 w U ME I AL HIISST,,RYlALLERGIESiMEDS , �{ �rll//LLii��GG z ci �� r MEDIC N TIME ATMPTS IV(SOLUTION,NEEDLE,SITE) :.....:_ MEDS y� PHYSICALEXAMlfREATMENT , �PT�t ��® �L 4 1A ,1,J CRO L RESPONSE TO TX: 3�"1 V r l�-L 71 1-�w�o n .-u- �'' hocre� e I,� 51 lac . In ►�f ( C -t (y U :L ( - a 1�„1 •• �� � � �. 1 1 1 • �1�^ , � ' t I�L MEDICS TIME MEDICATIONS(TYPE,DOSE,ROUTE I C N Z. Cr�15.�..�.��-� -� b;��- . � .tom.�.xw..• �� �rt� ; - , � a.k-y c, Ire SU k Ted �•. 3 _ ���siov� t � l ._ ii 4 1 � .. ..,.. '-[tr I - 2 �` � � 1 N URE /� IMP ESSION ntMA�'� .IfOILOW UP? IVI fi� fJ� ( �{4- f C<�� GAS.j(',n�a�t tq ( ( t— rr`` WAIVER OF LIABILIN:I refuse treatment and/or transportation by Lakeview Hospital A. Inc.Inc.EMS Department.I u derstand In doing so,I assume responsbility for my own,or my child's own. medical treatment I have been advised to seek the attention of:physical.I release Lakeview Hospital Association,Inc.,including,but not limited to its EMS Department,and its employees,diicers,directors, vdunteers and agents from any liability resulting from my own,or my child's own refusal of medical treatment or transportation. 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N 0 .. garg oo0m wHt'n ha 0n o 0 n �O x �o0e MHro 0 1414 m OP H 0 ✓ 0401 tb'Ok 040 OHH 014 0 . 0 • xl H W. r. 00 roO O 0. \O w° I-I 00H0 wW V 0 ooyn0 '47- Hn coy 0 tii il ti 00 H O O W H HZro O• 0 O` • • HH O 0'` Oro 001< OW 14 H b W •0• 01.3 an ll 0 V 0140 HO H o AO LV 641 'y oO y 11 �`'ro. 006000 0Z H - 0M O NI a II0 60i H • 0 H y 6C o f, ti to w Lit y en twit H 0• Ht" a O n0 a • OH O0n w O H t , X _ Berkley • Administrators PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN 55426 Phone (612) 544-0311 • Fax (612) 591-7404 September 11, 1995 La Vonne Wilson City Of Oak Park Heights PO Box 2007 Oak Park Heights, MN 55082 O n�� RE: LMCIT Workers' Compensation Program D 1J Policy Number: 02-729 Policy period: 07/07/94 to 07/07/95 SEP ` 2 Dear Ms. Wilson: I will be in your area on 09/19/95 (AM)to audit cities participating in the League of Minnesota Cities Insurance Trust Self-Insured Workers' Compensation Program. The purpose of the audit will be to determine any balance of premium that may be refundable to or due from you. In order to complete the audit in a manner fair and equitable to all cities participating in the program, the League has directed us to examine certain records of participating cities. Please make the following records available to me covering the policy period: 1. Payroll Journals or Registers 2, Individual Earnings Records 3. Federal 941 and Minnesota Department of Employment Security Quarterly Returns. 4. General Ledger 5. Cash Disbursements Journal or Checkbook 6. Contracts for services and certificates of insurance from vendors. 7. Fire contracts with other cities and townships 8. Resolution or ordinance providing WC coverage f o r elected or a pp ointed officials. 9. Police and Fire Department Non-Smoker Statements. 10. Summary of Worker Hours for Volunteer ambulance, police reserves, and 1st Responders/Rescue Squad. Please call us if someone from your office will not be available on the above scheduled date. Sincerely, Jeff Koschmeder Auditor Member of the W.R. Berkley Group Berkley • r_ III Administrators PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN 55426 Phone (612) 544-0311 • Fax (612) 591-7404 August 18, 1995 � � �D f La Vonne Wilson AUG 2 1 995 lip Oak Park Heights PO Box 2007 Oak Park Heights, MN 55082 RE: LMCIT Workers' Compensation Program Policy Number: 02-729 Policy period: 07/07/94 to 07/07/95 Dear Ms. Wilson: I will be in your area on 08/28/95 (PM)to audit cities participating in the League of Minnesota Cities Insurance Trust Self-Insured Workers' Compensation Program. The purpose of the audit will be to determine any balance of premium that may be refundable to or due from you. In order to complete the audit in a manner fair and equitable to all cities participating in the program, the League has directed us to examine certain records of participating cities. Please make the following records available to me covering the policy period: 1. Payroll Journals or Registers 2, Individual Earnings Records 73. Federal 941 and Minnesota Department of Employment Security Quarterly Returns. ✓4. General Ledger 5. Cash Disbursements Journal or Checkbook $�Contracts for services and certificates of insurance from vendors. ep Fire contracts with other cities and townships —8. Resolution or ordinance providing WC coverage for elected or appointed officials. -----9. Police and Fire Department Non-Smoker Statements. ,A 0. Summary of Worker Hours for Volunteer ambulance, police reserves, and 1st Responders/Rescue Squad. Please call us if someone from your office will not be available on the above scheduled date. Sincerely, Jeff Koschmeder Auditor Member of the W.R. Berkley Group Berkley Ainistrators • PO Box 59143, M is., MN 55459-0143 • Phone(612)544-0311 • Fax(612)591-7404 P ( } i ) INSURED CLIENT: CITY OF OAK PARK HEIGHTS #2 P.O.BOX 2007 LMCIT OAK PARK HEIGHTS,MN 55082-2007 AUDITOR NAME: Jeff Koschmeder POLICY NUMBER: POLICY PERIOD: AUDIT PERIOD: FILE ID: DATE;' 02-000729-08 07/07/94 To 07/07/95 07/01/94 To 07/01/95 1314982 09/19/95 Page 1 of 6 SUMMARY PAGE KEY= A-AREA B-FRONTAGE C-REMUNERATION D-SATES7RECEIPTS E-COST F-ADMISSIONS -G-PER CAPITA/EACH K s R CLASSIFICATION E A CODES BASIS OF A PREMIUM y T PREMIUM T E Workers Compensation Summary GENERAL MAINTENANCE C MN 5506 70,672 POLICE C MN 7720 335,546 CLERICAL C MN 8810 140,264 PARKS C MN 9102 41,206 MUNICIPAL EMPLOYEES C MN 9410 31,709 ELECTED OR APPOINTED OFFICIALS C MN 9411 16,380 SKATING RINK OPERATION C MN 9016 5,009 TOTAL 640,786 LESS AMOUNT PREVIOUSLY BILLED EARNED PREMIUM LESS PREVIOUS BILLING LESS DEPOSIT PREMIUM HAP OR [I RP DIVIDEND BALANCE DUE [!INSURED[1 COMPANY CIT AUDIT CITE CAST ST City oak Pa A W1 M Agreement Dates 77/95/ - 1.5 Date 9k/�.,. Employed Yes No Comments Assessor / . Building Inspector V Garbage Pickup t/ 60,--;,,; G.14--� Police Protection Snow Removal Volunteer Fire Department Population • Name Sections %Total Tatat Pap Pap Served oVC•G64 h+! Total Yes No Comments Mayor & Council Resolution 1 0 — ,cx lox 52 = )s,'zoo - 12,600 Boards and Commissions Resolution Volunteer Ambulance 1st Responders/Rescue Squad Are 1st resonders/rescue squad members on the council approved volunteer fire dept. roster? Police Reserves t/. When City uses subcontractors does it require them to supply evidence of compliance with MN workers' compensation law? 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N N co co UU W c Ct.8IX 2 #£ (-) < M 7 y d-t~O1v-NN0M0 Ito 8 z m 4 Q. 0 tri o.- r(O U) ti 5 �' y •p nmvvM .- Q U M m y d y m m 4 vo o 690 o z3" v 0c)- .o O u-) coo) ¢pai0 m 3 £ E n r 8 15 p •G , � N 0 3CC 1"' C-) W W S O ` O U O ip d 4 1-4 E C Z w r a , w ` Q • • Special Compensation Fund (612) 296-2117 Labor and Industry Building Telecommunication Device 443 Lafayette Road N. & the Deaf (612) 297-4198 St. Paul, Minnesota 55155-4317 Fax: (612) 297-7098 Minnesota Department April 24, 1995 of Labor & Industry Dear City, County, or State Administrator: This letter is written to inform and emphasize the importance of your compliance with Minnesota Statute §176.182. This statute requires that every state, county, and city licensing agency shall withhold the issuance or renewal of a license or permit until evidence of compliance with the workers' compensation insurance requirement of Minnesota Statute §176 is furnished. Your compliance with this mandate should have a significant positive affect in combating the problem of employers not insuring their employees for workers' compensation. Information you collect from license and/or permit applicants should include: • the insurance company (not agent) • policy number • dates of coverage • signed statement whereby the licensee certifies the information given is true and the policy will be kept in effect during the license period. You may use the attached statement as a model or make copies to include in your license packet. You are to keep this information in your files. The form should be filled out by the applicant in their handwriting or typewritten by the applicant. The licensing authority should not fill in missing information for the applicant. All applicant signatures must be dated to assist with potential future action by the Department of Labor and Industry. Questions regarding whether particular employers must insure under the Workers' Compensation Act may be directed to the Assistance and Compliance Section of the Department of Labor and Industry at (612) 296-2432 or 1-800-DIAL-DLI. Questions regarding enforcement of these statutes should be directed to the following Special Compensation Fund Investigators: John Harlis or Jim Wright for the metropolitan and southern one-half of the State at (612)296-2117 or 1-800-DIAL-DLI, or John Miller, for northern Minnesota and Duluth, at (218) 723-4670 or 1-800-365-4584. Sincerely, oX.eveivv.L Brandon Miller Acting Director tVz, TT 172 enclosure 3 II 4 i App 2 4 !I An Equal Opportunity Employer (AFSpME) Wqx pxt • -CERTIFICATION OF COMPLIAN-CE- MINNESOTA WORKERS' COMPENSATION LAW Minnesota Statute, Section 176.182 requires every state and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the workers' compensation insurance coverage requirement of MSS Chapter 176. The information required is: the name of the insurance company, the policy number, and dates of coverage or the permit to self-insure. This information will be collected by the licensing agency and retained in their files. This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided and/or is falsely reported. Furthermore, if this information is not provided or falsely stated, it may result in a $1,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. Insurance Company Name: (NOT the insurance agent) Policy Number: Dates of Coverage: to (or) I am not required to have workers' compensation liability coverage because: ( ) I have no employees ( ) I am self insured (include permit to self-insure) ( ) I have no employees who are covered by the workers' compensation law (these include: Spouse, Parents, Children and certain farm employees) I certify that the information provided above is accurate and complete and that a valid workers' compensation policy will be kept in effect at all times as required by law. Name: (last, first, middle) Doing Business As: (business name if different than your name) Business Address: City. State. Zip: Phone:( ) Signature: Date: I 1 ■ • , 0 N Ch Ch ro H N isl i rye 0 0 WOW rH vi+►m H ng 2:,1,0m m N W r D O wn CN N tb � k. . 4yy . n0 NOH NH H C)ii WWg 50 85 III 41 0 O N N 41 H rol nNox U PA 0 0 0 g H il 0 ra n k @N MO 00 $ rn Nit W tJ7d N • HHN H 0 HOZ yy�Wgxn N pl G :e 'C 'A CD qo H bo H OH vii jay noWY1 H b H O M H H O H W W WO O NO HOMN x x * S)1 w i N t+ W ro d H H ; pO O H on !G NH o o O NA oom .....44V or w Lyn o pa OOO v ro man gy 0 Vg Z 45 NNHKG M "'IC w �rO+ 0 Nx N N0 H ON ✓ OHN r0�iCC rb o00'.3O 3d OH 140.3 RI H \\\ 00 100 HZ NHHL-10 J 0 N,3Gro \\\VV WWO Hx l4 iaHl' WW wM a n lampym ^4.0. 0\ � NH µbr o r H wgW• 0 duos: J 0 NH H • H $ ..IA O HZ [7 0010 a H h$ C' \ MM Oo H 10.4 0 • 0 y\ ro 0oy Hr NN 0011 HOw xW 0007aou1 �n�y 0 o O y 000 G HO H MM 0 W H H W W H ' d aoNNd 00WW Po Po 00W z O O N N 000W O hi m 0H ^ooi 0 & NH • • •e CN H FN+• CV 00HW 0 C0 ■ 0 FA N \ PA 0 W W Al H N •• • •N 0 H ✓ H 000HLy 'o no w • OHy nnomn W 0 Ht' 00'0 • • 8 o A o 5c En z M E h"i i 011:1 O7z C� m Q 0 gP 0o @ p 0dt H 0 m co 0 m m H H Z 7 t . • n t4CO m o � ' r" ►-, ,tt.• Z s .g... m gyCC 0 O t=i L. to O • d Z IW 1 i • C N S En Iv H cn x t) oc 8 I-0 M I H Pd v H x z x "d H 1-3 tTi I-0 0 t=i p b ni t7 H H 0 0 t7dpO 9 7J Pri p 0 zoo R H H t ti tri .y HtrJ H H En C7 . 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C� .0H!�H 0fAt'W ;u m r O to nn MZM _c) AO MOH m-n �+yH H Qgg� "sue Gil i..) k N Inn] toQS' OP roe ;nz z roN L t ,] lazO yAHl Mm l / 't4 I t4 n 1014 . 10 11.4 mmto pc tic) mm�£4 340 m H H H m H O PI N PS Cotlm vgxa0ro nc))7¢ M OH H V 44 H�flL4H H�O!H W HO t$i p{ ::4 U1 gy•'4 *73 QQ N DI C I ii s; WHd oh.GU1 H A0 '4H ON.. xoWWm ..-.03V dtt1 NNLA O -- N mLar M o r ro 00 N 0 NH M tiNro o Nz N 03 m Off+' H Wm H ✓ oHm r C7 1A4 ti Po opKo 0 0 o l4 'If 1.3 HoN 0 Hoo • NH Nma ■■■ Cl o ro O � N ���OK 0 0 z o0OV ■■■mao H N.4 Hey mm loco .4 Q aN G 1PAA NH A wr) a 1Cr I mw Po 0 0.4 0 0 m H H oro °ooNr ' xm Po OOZH t"roa 0 • • HHC7 y'\ 'U NW 001E 3 Om Z H b 03 o o o X I V 1 O ro 000N 0 0 0 O HO H 101 N yLa La N 123 ro N H Po Pd 0014 oow£ H o O N m M 000La O M row La ro m K H 0 HM 0 H MO. . .. P H • C to 0omN to o m La N ■ O H N \ N 0 l0 O W H M N • • •n 014 to y 000Hr m W 00 H O OH OAOHr 4+ o Hr rororo mmmXp APPROVED OMB NO.093 -0279 LAKEVIEW HOSPITAL 2 I )1 3PATIENTCONTROLNO. P 0 BOX 1425 40283426DEC940 131 MINNEAPOLIS MN 55480-50 5 FED.TAX NO, 6 STATEMENT COVERS PERIOD FP.OM THROUGH 7 COV D. 8 N-C D. 9 C-I D. 10 L-R D. 11 612-439-5330 41-0811697 122694 122694 12 PATIENT NAME 13 PATIENT ADDRESS,. BUCKLEY STANLEY L 14448 55TH STREET STILLWATER MN ADMISSION 55082 ION S 14 BIRTHDATE 15 SEX 16 MS 17 DATE 118 HR ,19 TYPE 20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO. 24 OOND(T GOE28 31 07141952 M 122694 19 1 7 01 402834 j 02 OCCURRENCE 33 OCCURRENCE 35 °OCCURRENCE,." • O ENCE SPAW 137 CODE ;DATE ODE D.YE CODE DATE oi'D 'AT CODE FROM THROWN A A a B B b _ C 36 BUCKLEY STANLEY L 000 VALUE CODES 40 VA U AMOUN7 4CODE VALUE AMOUNT 14448 55TH STREET a a b b STILLWATER MN 55082 c c d, I _ d 42 REV.CD. 43 DESCRIPTION 44 HCPCS I RATES 45 SER4 DATE 46 SERV.UNITS 47 TOTAL CHARGES 48 N051-COVERED CHARGES 49 1 272 STERILE SUPPLY 1 21 ; 80 1 2' 450 EMERG ROOM 99282 1 56 , 70 2 3 981 PRO FEE/ER 1 115 ; 50 3 4 I ; 4 5 5 6i 6 7 7 8 i 8 91 9 10 10 111 0 Lakeview has 48 beds 11 12 12 isn't subject to the 12 13 15%reduction per WCL 176.136 1a 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 23 001 TOTAL CHARGES � 194 . 00 _ 23 50 PAYER 51 PROVIDER NO. 52 RE4..63 AS0 54 PRIOR PAYMENTS 55 EST.AMOUNT DUE 1 56 INFO BEN , A WORKERS COMP Y Y B C 57 DUE FROM PAT/ENT 58 INSURED'S NAME 59 P.REL 60 CERT.-SSN-HIC.-ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. A BUCKLEY STANLEY L 01 476622154 CITY OF OPH A B B I C', 63 TREATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION A 1 CITY OF OAK PARK HEI OAK PARK H MN 55082 A B B C C, 67 PRIN.DIAG.CD. OTH 'JAG.CODES 76 ADM.DIAG.CD. 77 E-CODE 78 I m GODS '" oCDm 70 006E �� o;.. 72 CODE AWN S 7=��.i� , 9181 >>. 917 79 P.C. 80 PRINCIPAL PROCEDURE '81 oTHS PRCCEDURE 82 ATTENDING PHYS.ID a CODE DATE CODE DA7E �. 5rV DE GEAR DAVID b OTHER-PROCEDURE S cooTHER PROCEDURE 83 OTHER PHYS.ID a CODE GATE - < i J1 I b a 84 REMARKS OTHER PHYS.ID a b b C 85 PROVO REPRESENTATIVE 86 DATE d X ,kilatli 010595 UB-92 HCFA-1450 OCR / ORIGINAL I CERTIFY THE C RTI'CATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. 40 EX HOSP 1874H PATIENT BILL MEDICARE 24-0066 -� LAKEVIEW 927 West Churchill eet IRS 41 0811697 OPW 0101712 Stwe , 02 . HOSPITAL (612)439-ill5330 atrFax MN(612)8 430-4660 STANLEY L BUCKLEY STANLEY L BUCKLEY * 40283426DEC940 Outpatient $ PATIENT NAME RESPONSIBLE PARTY MED.RECORD NO. TYPE AMOUNT REMITTED 2 PLEASE DETACH AND RETURN THIS STUB WITH YOUR REMITTANCE TO INSURE PROPER CREDIT. STANLEY L BUCKLEY 40283426DEC940 143UL1952 1 PATIENT NAME J MEDICAL RECORD NUMBER BIRTHDATE PAGE NUMBER POLICYHOLDER NAME/ADDRESS INSURANCE INFORMATION STANLEY L BUCKLEY Primary: WORKERS COMP 14448 55TH STREET Id No 476622154 Gr No STILLWATER, MN 55082 Secondary: Id No Gr No Tertiary: January 4, 1995 December 26, 1994 December 26, 1994 DE GEAR DAVID BILLING DATE ADMITTANCE DATE DISCHARGE DATE PHYSICIAN DATE SERVICE CODE DESCRIPTION QUANTITY UNIT PRICE AMOUNT CHARGES 26DEC94 2505710 A4550 EYE TRAY 1 $21.80 $21.80 26DEC94 2703173 99282 LEVEL II EMERGENCY ROOM 1 $56.70 $56.70 26DEC94 2711283 99283 LEVEL III PHYSICIAN 1 $115.50 $115.50 , SLIIMARY OF CHARGES/PAYMENTS EMERGENCY ROOM $56.70 PHYSICIANS $115.50 MATERIALS SERVICES $21.80 Total Charges $194.00 TOTAL OF CHARGES/PAYMENTS $194.00 THIS IS A COPY OF A BILL WHICH.HAS-BEEN SUBMITTED TO THE ABOVE INSURANCE ON YOUR BEHALF. IF THE INSURANCE CARRIER DOES NOT MAKE PAYMENT WITHIN 30 DAYS FROM THE BILLING DATE, THE BALANCE WILL BE YOUR RESPONSIBILITY. ice, �T�� TOTAL lk $94.00 LAKE V IEW 927 West Churchill Street HOS PITAL Stillwater,MN 55082 T I (612)439-5330 Fax(612)430-4660 H CV LAST .. ;; ; •: +r 't Mb t� ill ER1 t , 1 CO TIME , - ':,,r.. 4. ATE . j 10 tcf NAME: / �' �, �, F� a �(, �. gyp _ s - PHONE Z M ADDRESS: ' W ::-..c,:::,.. . _ TM .. '.: 'x CITY A ZIP . 7:- f 7 `` 2 in- :r ,,. - y,;}; �. •: RELATIONSHIP: BD: AGE: �.• di RESPONSIBLE PARTY: 7r{ti- '- :;..<' 1' SEX. u. `"'....: 5;::. .l.': t. . ` .,;is MSWD: '' 'r w .4r INSURANCE CA: -;ter _.ti.,.,.._: ,;, :° aw; / ' SS1t:. COMP.: :r: ..t Q INSURANCE' IER. .. •: , . r,�.: =:,_.� -�.;, ,3 . I!. ... _• `r' EMPLOYER OF INSURED .` '17,•::' `.ADDRESS • r ''` t-, • :'�• :; „ J .•-.asaa:,..:.�:.._,zeF !.: •xrs''ria5,t r v Y 4- s Bi:- ,�S I.� P " >a''a:-^gyp,' ..k4.,,,,-00! IC—A TREATMENT AI�1 i11OMi'- •` x,��...,> • 5.. > d F R ES 4 w e ' ' nyr s: TETANI; :aviii,;,:'f`* t ' '�` .7 +rk'. • t � �* 'a k i`i F - ' y.. �' .,> .' q t'gy' k,, Nab; l(/ �•` + I 1JIEDS k `zs a ,, M S.. , •' - �FxsV",` . a�.»' ,1 '5 .41 # ' M M:e.sAi ;y�FO.r} .- _ .,'-'1,c,',.::.-7 ° ..,s u .CONIC r»g5,, SEEN St_ .,..k :;: NOTIFIEt]t,j' ` tea 4 ARRIVED !7o PRIVATE MD ', 'ij'1�/tyre,` " I. NU,RSESASSESSMENT:,, -4: • . �,,� .'��..: ��..� �,, '-TIME ~TEMP PULSE RESP er'• .... .�" e'4 . ; ' 1,Sir i`•1/`•,:U •13 r?4l. `fit• :' ✓. . .s. /Jot leo , .4y1, i ,.:. ,1.4,4''''' ..� rt: 3i xr ...,.r .,..a S 9._, ,_E ''kx TA. �'. f .. ; '�: "",.`, j .-.a, y1.ls. ,aj-7. ....! -"a."A. 3 ,,i'.,, "` r 7', "-i `ki�i k: ;?,.10.40. -,g;' it:t te..:°K:si R .,?",,,.v..-. ::. 2; `¢'aat.?{`, *c-,,,,,9'., :1A y ~ -;N W ��-� - '� — ,TIME MEDICATION```S y”*� ,� ff,_'s,.r .v .�-a'r .uV,G. :r r fdS ' t '',.,' S r •`r -', '$YR'a;}t�`E,'�', '_f-a. ' d f,••I. ; "";; = ,:z � .a,�,.-,�'a ti > i }"��v ,�'!x5 ,..,,-;:!. s .},j.s•.,,, .,-.* .,„4,oifri+44, r;N` .° ,.• t p� s ''''.*• ��"Z !-- "�� �� '4 �'u Wit" �'% .- '7: #' w�r � < Ar �y. rt /� I �i j�, W: • .'' C 4 '`''.' , jK', ,!1 k"7-M}. ! ^.E y All 4' if URSES SIGNATURE g (�� 44,,,...,.,- ,yam; A• 4--.--,,4,„,„-:, Hz 4.-.1-„,,, 1,. ;7. fi"•a- .a• t Ltil, ,� G 7�/ 1 t,.. 5 . . '.+, ,,,r “ V,,,,z 14.• J,S AN.fy ts, .:t •4 • f s ['f•••A�'ny—� ,...■.... : -.... .�.ww,•�� tn hi F s . ,.ery fidt •6 w Y F -k . :,.,,',7,7, v .+ ° i v.Ili-- t * -..,1 bt '*: l , , - i. .,..,:-..,...t.:. :,.-, - ..'*.w.,T4rl'Q'r”'-g .^Cf"�„4,,,. .'r�w.rT'^ .' 7,,,�'1r,e+.wCa„a',a�'4 : y .gSl�,� � . r/� 4• . �. :.—o..n'^R^.r '"'"..,.r... e•?'y„'''' ,,4 ,• „ .•.�'.r r^'"xcF r 9- .t S .0 9 !'^,T^ • '.--- 4';. '+ y..vds..+.ri: .• .. • w+,.v - �....:.._8.ar...3'..._.r » 0. `.;�+,>6�L:,d.itia:� .,..�.......-...-..aJ �L..•rac„e. E' . • 1 _ .imr t .; ...:., _ ,3. , a «: i• ,a. iff)'rte.«. M,,,. ..+xJr, -'r +fir,; Z,.,, `r"' ,t, K c' r'� ,.14! • r - WJ H Wr'IOM 4 K � .. .� •��',`� wf , R r' '�dam, F �•n'�.4.- -si17,L'!h 1� -:A*,.....4.,1,4t.-. ca) • Berkley Administrators PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN 55426 Phone (612) 544-0311 • Fax (612) 591-7404 (�? f1 October 7, 1994 ) E v CE OWE �/7 E City of Oak Park Heights OCT ` I ATTENTION: LaVonne Wilson 14168 - 57th St. , Box 2007 Stillwater, MN 55082 RE: EMPLOYEE: Jimmy Allen Butler DATE OF INJURY: 7-14-94 CLAIM NUMBER: 2-729-263628-P8 On September 26, 1994, you were notified that primary liability for this claim was denied. Further investigation, however, has indicated that it is compensable under Workers' Compensation Law. Please forward any related correspondence or bill s to me for review, referring to the claim number above. Should you have any questions, please feel free to contact me. Note the claim number above. Please write it on anything you send call. D to us and be sure to have it available if you Doing so will ou all. o in speed the handling of this case. Sincerely, VQKCIJOa(AW,i4LQ Kendra Wiswell Medical Correspondent (612) 525-5772 KO/rca cc: Jimmy Allen e c: immy Al n Butl r 7764 Carnelian Lane Eden Prairie, MN 55346 Healthworks, Inc. 3033 University Ave. SE Minneapolis, MN 55414 Member of the W.R. Berkley Group • as. • ld Berkley Administrators PO Box 59143, Mpls., MN 55459-0143 • 8441 Wayzata Blvd., Mpls., MN 55426 Phone (612) 544-0311 • Fax (612) 591-7404 September 26, 1994 Jimmy Allen Butler 7765 Carnelian Lane Eden Prairie, MN 55346 RE: EMPLOYEE: Jimmy Allen Butler DATE OF INJURY: 7-14-94 CLAIM NUMBER: 2-729-263628-P8 Our investigation of this claim indicates that it is one for which you have no responsibility under the Workers' Compensation Law and that payment on your behalf is not warranted. The condition did not arise out of employment activities. The incident, as reported, is not unique to employment activities. The employee was at no greater risk than the general population. We believe you are quite well acquainted with the facts of this claim, but if you have any questions, we would appreciate hearing from you. Note the claim number above. Please write it on anything you send to us and be sure to have it available if you call. Doing so will speed the handling of this case. Sincerely, Kendra Wiswell Claim Service Representative (612) 525-5772 KW:rmb cc: Healthworks, Inc. 3033 University Avenue S.E. Minneapolis, MN 55414 Member of the W.R. Berkley Group - BILLING DATE EMPLOYER NO. PATIENT �� -- - - --- ~~~~~~rkS 08/ 4 0199060603 077370*1 i � �~ �����p�wn .&| ����iCiD� ��O��r8 ���� /Y - - - ' ' Medicine ���r /k � '� ' ' / ' /�'--��N� EMPLOYER ~ / w / ‘ / `� ' ^ ' CITY OF OAK PARK HEIGHTS '` /` / � PO BOX 2007 (T OAK PARK HEIGHTS, MN 55082 /- CITY OF OAK PARK HEIGHTS —\ � REMIT TO � PO BOX 2007 / *s��*wonusoccupATmmAu MEDICINE CENTERS OAK PARK HEIGHTS, MN 55082 3033 uw/vans/r/mEwuso.s. m/mwexpouS,MINNESOTA 55414-3380 T0 1612)379-7244 TAX/o#w'1sooso1 . IMPORTANT. ���ynm`mx PORTION WITH YOUR`- ) BALANCE DUE pAvMsm/ amoomr $106. 78 ` DATE PATIENT 1 PATIENT uz ' 08/31/94 BUTLER, JIMMEY A. 07730 4 SOCIAL SECURITY NO. - -/ "^v ., yxv^i 'mx o/xmrxnm H.',1;(;1 Injury Date: 07/14/94 1st Seen : 07/29/94 Diagnosis: 840. 9 - SPRAIN/STRAIN SH./UP.ARM, NOS 08/02/94 BALANCE FROM PREVIOUS INVOICE 68. 74 08/17/94 99212 ESTABLISHED PATIENT VISIT LEVEL 2 ( JH/02 ) 36. 44 08/17/94 RECORDS/ MEDICAL RECORDS-WC/PAGE ( JH/02 ) 1. 50 2PGS 08/17/94 TAX SALES TAX / MEDICAL RECORDS ( JH/02 ) 0. 10 08/17/94 01201 PROVIDER ENCOUNTER-IN CLINIC ( JH/02 ) � ' -/ � �� �� ^ 71 Cr ' ■0 ! PLEASE R J � • ' 1 b ° ' ' /° ' . BALANCE DUE 106. 78 ' 0. 00 0. 00 0. 00 0. 00 n - - CURRE NT OVER 39 OVER 60 OVER 90 OVER 120 EMPLOYER'S COPY HWO16F / BILLING DATE EMPLOYER NO pm�wruowo PAGE' HeclWhWoiks 0 8/3 0199060603 Occupational Medicine • \� �� � '~~�^~^ EMPLOYER | '. / '` CITY OF OAK PARK HEIGHTS PO BOX 2007 OAK PARK HEIGHTS MN, 55082 CITY OF OAK PARK HEIGHTS -\ REMIT TO ` *sxonwonnooncop�now���so�/mscswrsnm PO BOX 2007 3033 uwwsnsnvm�mueo� OAK PARK HEIGHTS MN 55082 , M/wms«pouo'MINNESOTA osw*�nou (612)379-7244 �X/oww�aouou1 � /Mp«»'��`/������������yk�»wTHIS ( / umxmnuu/ rxvm/ m \m'/1/m/ `- -/ / � _ BILLING DATE PATIENT NAME [---,ATIEwr/u SOCIAL SECURITY wu / xvx / ' ``o/ m `' xo'm`w ** S U M M A R Y ** TOTAL INJURY RELATED INVOICES: 106.78 TOTAL NON-INJURY RELATED INVOICES: 0.00 TOTAL: 106. 78 ========== , | UU w� A �� � N�� �1 �w » w�� CITY OF OAK PARK HEIGHTS *mxm� / DUI ovv,zo ov/ ow ovmsn uvm ou EMPLOYER'S COPY HWOMF • ."' ____". ATTN LAVON•W I LSON APPROVED OMB-0936-0008 CITY OF OAK PARK HEIGHTS 14168 NORTH 57TH OAK HEIGHTS PARK MN 55082 PICA HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS •OHAMPVA GROUP FICA OT HER(1a_INSURED'S I.D.NU1.1BE? (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare#) 77(Medicaid #1 pi (Sponsors SSN) i7' !VA File 1 ,�: ISSN or ID S J, RAID) 1 474529108 ,I 2.PATIENTS NAME(Last Name.First:Name.Mlode iuv.) +. MM PATIENTS BIRTH DATE 4.INSURED'S NAME _as(`la-a.First Name,Middle initial) DD YY SE.X 1BUTLER, JIMIIEY A. � 06 16 47m1XX F71 I CITY OF OAK PARK HEIGHTS 5.PATIENT'S ADDRESS No Street) 16.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS•No Street) 7765 CARNELIAN LANE I sot 77 Spouse7) ChldV C•r,er;i( 14165 NORTH 57TH CITY I STATE 1 8.PATIENT STATUS CITY STATE EDEN PRAIRIE MN' Single Pi Married XX Other OAK HETGHTS PARK MN • i ZIP CODE TELEPHONE(Include Area Code) ZIP CODE ,TELEPHONE(INCLUDE AREA CODE) _- 151L •• Employed- Pull-Time P n T.me c••c;• �,.�.345 (612) X34-9492 XX 55082 (612) 439-4439 S dent az ucent 19.OTHER INSUREDS NAME(Last Name,First Name.Middle Initial: 10.IS PATIENTS CONDITION RELATED TO: 11-INSURED'S POLICY DRG_=FOR FECA NUMBER OTHER INSUREDS POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OF PPE d;OUS) a.INSURED'S MM D DATE D CF 2'RT'- SEX ,XES j NO M F b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME DP S2-00L NAME MM DD YY M F; Li YES rrAo • c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME C3 PROGRAM NAME [ ,iXES I NO d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH.BENEFIT PLAN? YES i i NC If yes:return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENTS OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefit=_:o the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myseif or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE_ i�LE______- DATE 8/02/94_--_----- SIGNED SIGNATURE FILE ON ILk 14.DATE O�pF�}CURRENT:y ' ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE 70 WORK IN CURRENT OCCUPATION 1 +Y4 PREGNANCY(LMP) I GIVE FIRST DATE MM • DD YY FROM MM DO YY TO MM ' DO YY 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 16.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM • DO YY MM DD YY FROM TO 19,RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES • J7140 - MEDICATION - BILLED WHOLESALE PRICE YES 1 NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY 22.MEDICAID RESUBMISSION • CODE 1 ORIGINAL REF.NO, 840. 9 SPRAIN/STRAIN SH. /U Y • _ ._-_ 1. L . 3. L__._ 23,PRIOR AUTHORIZATION NUMBER 2. 1--_._ 4. 1 24. A B C D l E F G 1 H I J K From DATE(S)OF SERVICE Place Type PROCEDURES.SERVICES.OR SUPPLIES DIAGNOSIS DAYS IEREDT RESERVED FOR d- of of (Explain Unusual Circumstances) CODE $CHARGES OR i Family EMG COB LOCAL USE MM DD YY MM DD YY Service Service CPT.HCPCS I MODIFIER UNITS 1 Plan 'r i • 1 07/29/94 7/29/94 3 99202 1 1 67. 14 1 to l:• • 2 07/29/94 3 RECORD) /WC 1 1. 50 2 I e • Li G. 3 07/29/;94 3 TAX 1 10 1 • • 4 07/29/94 3 01201 1 0« 00 1 r a r z a 5 Ir� (• 3 6 • I; !0 a 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE ,29.AMOUNT PAID 30.BALANCE DUE j i (For govt.claims,see back) 41-1558621 I 077370*1 1 YES !i NO $ 68. 74 5 $ 68. 74 31,SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S.SUPPLIER'S BILLING NAME.ADDRESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED()f other than home or office) &PHONE 4 (I certify that the statements on the reverse apply to this bill and are made a part thereof.) HEALTHWORKS, INC. JOHN S. JACOBY M. D„ 3033 UNIVERSITY AVE. S. E. SIGNED DATE 08/02/94 PI(` IINNEAPOLIS, 100» 55414 (,APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8.881 PLEASE PRINT OR TYPE 612 '�I r�_T 44Rn1 HCFA-1500 i 12-90) POR.M OWCP)1500 FORM RRB-1500 ua•8ad S9:° •Sa')a°,o`.p u<.�°u°die+"` .�'�. ed ° DATE: /� I COMPANY: '� J ���� f}�r/� ito ALLERGIES���(�� /✓ RX'S: l NAME: 1 Y /7 At II /// �` DATE OF INJURY: 77/4//. / i/L in 4'S4u�G - . .L BP: / ''7 HISTORY GIVEN BY PATIENT: �7 PT HX: /3/ . L:?!L 1 it NI i% IP Y t. .0 I it.."a1/4. IC . ( IL tJ k,j" &A Gi Q.('' _ L_r A 0 4�L ..L '4.J n `` �z—%j• * tA10 2 p U t1 o 0t: ..a_to . L 7�t x/k ) t ) va1Q . MAe • Vii._, - • II Ilk , IIIKMNIIMM .11111111MININSIPMPIP416 IIIMIIMIIMIMIIIIFRIPOIL r►- _ , (i t ' i 4.1-ipp if - . , -_----i __ .- •- ,, n. orKS g vcQupational Medicine Centers Name : BUTLER, JIMMY A. Employer : CITY OF OAK PARK HEIGHTS D-O-B : 06/16/47 D-O-I : 07/14/94 Chart No. : 206136 Date of Visit : 07/29/94 Diagnosis: Strain, left arm and shoulder. Work Related: Yes. History and Physical Examination: Patient states that on 07/14/94 he was getting up out of his chair, leaning down or raising himself up by pressing down with his arms on the arms of his chair. His hands slipped off of the arms and he came down fairly hard on his buttocks. Immediately he had some rather sharp low back pain which fairly promptly cleared, and he has not had recurrence. He did, however, develop discomfort in the left shoulder and arm which has persisted. He states that he does not really have anything in the way of very significant or severe pain, but he has a tingling and numbness kind of sensation that seems to start in the posterior shoulder and then radiate down involving essentially the entire arm and hand. This sensation will come on if he grips with his left hand. The tingling occurs in his hand and radiating up into the arm and shoulder. He denies prior injury to the shoulder. He denies pain in the neck. On examination he has full, free range of motion in the cervical spine without pain or aggravation of symptoms. Distraction and compression in the cervical spine do not produce pain or aggravate symptoms. Examination of the shoulder shows some minimal tenderness over the biceps tendon in the bicipital grove. There is full range of motion in the shoulder without apparent aggravation of problem. Deep tendon reflexes are active and symmetric as far as biceps and triceps reflexes are concerned. I have discussed this at some length with this patient. I do not have a definitive diagnosis here other than that of strain with some referred symptoms as a primary possibility. There does not appear to be radicular problem arising in the neck, and there is no history that would really suggest brachial plexus problem. Treatment: My recommendation to this patient does not involve any specific treatment at this time but rather observation for a week or two to see what transpires. At the end of two weeks, if he continues to have paresthesias, I believe consideration should be given to EMG. Work Status: He may work without limitation. Follow up: Two weeks. THE ABOVE HAS BEEN John S. Jacoby, M.D. DICTATED BUT NOT READ Medical Director 1,;;;;1 IS CUBJECT TO Dit. tA,IION AND TRANSCRIPTION JSJ/sk \'t-ii .i`.:,. Transcribed 07/30/94 Northwest, 3033 University Ave. S.E.,Minneapolis, MN 55414, Phone:(612)379-7244 Bloomington, 600 W. 98th St.,Suite 395,Oxboro Medical Bldg., Bloomington,MN 55420, Phone:(612)885-6170 _vip; fvF ,S COP v HWO16F1 81111k DATE EMPLOYER NO PATIENT uzwo mm . _~~_alithWo= ks ��� v�����` �1/94 01990606Q3 Occupational Medicine Centers � / /— EMPLOYER CITY OF OAK PARK HEIGHTS 14168 NORTH 57TH OAK HEIGHTS PARK MN, 55082 /- CITY OF OAK PARK HEIGHTS —\ I nom�To ' *s�onwonm�oocupnTIowAL MEDICINE CENTERS 14168 NORTH 57TH a03x UNIVERSITY AVENUE o.s. OAK HEIGHTS PARK, MN 55082 m/wmsApou�M/wwcsmAm�1*�o� (612)379-7244 TAX m#w�auano � /111: `p �� � om,*,�� � PORTION WITH BALANCE 0o| pxvmfmramm/m| � ~ BILLING DATE PATIENT NAME PATIENT I^ SOCIAL SECURITY NO umf m unvx/ omI mscxmmm nmxe ** S U M M A R Y ** TOTAL INJURY RELATED INVOICES: 68.74 TOTAL NON—INJURY RELATED INVOICES: 0.00 --- TOTAL: 68. 74 � | BA/AMc/ DUE oxxf m/ OVE xz; '^»ne OVER 90 OVER 120 EMPLOYER'S COPY MAMA= Winners'Department of Labor and Industry Worker'Compa •structions First Report of Injury rtsrtion Dion St. Lafayette Rod North in folder accompanying forms. 1• eras 11111111 IIII MI11111111111 II St.Paul,MN 66166-4306 113121 298-2422 All dates must be entered in MM/DD/YY format. Type or Print. EMPLOYEE 2.Name(last,first,middle) 3.EMPLOYEE SOCIAL SECURITY NO: ✓0`"� eR. Aimfn'1 01Ierl . LI 7 �T `Ja -9/0E Ylir ..S0 4.Home address(incl de county and zi 1 5.DATE OF CLAIMED INJURY: • +/ . +C C-�i tf 1 1)j 'Q 414 Do Not Use this Space PIQ >AIk_tC. r+r)0 !"] , 7 1 I ft) S A ` 6.Sex: Male Female fk AA;f � 1 b / �/ 7. Marital Status: /Married _QNot 8. Occupation: A, 9.Date of Birth: .4 / its/ T 7 10.Date Hired: (o /9/ 7 3 II 5 re,eic re- 1 1.Regular Dept V t 12.Home Phone No.(A/C,No.) 13.Apprentice: No Yes - ftSP£- -fnh cola-93y- 941Q WAGE INFORMA N `, 15.Rate 16.Hours per day: 14.Average wage/week '7 744 �® / J 22 17.Days per week: 5 18.What is the weekly value of MEALS: $ LODGING: $ 2nd INCOME: 8 19.Employment Status: KFull time _Part time Seasonal Volunteer(Attach 26 week wage statement for part time or irregularly scheduled employee.) If employee is a police officer or firefighter: Smoker: Yes_ No OCCURRENCE 20. PLACE(include dept&full address) 21.Date of first A 22.Date employer ,j / Ct t� 0•9‘ oAk 'a �.-�e1a k+s day of lost time: 1 1_ notified of injury: (.2 C ,5 5 11-11 (4,1 n, 5 / 2 24.Date employer notified d 23.Return to work date:' _r 1 r"e 1 0 8 a X � ssos,z of lost time: ! J O tA k PA e k f��� _---- 26.Time of day �1 AM 3 /�1�� j�z i d tT i�) 25.Date of death: ! 1 of irtjtuy: 70 t O� ❑ PM Ortemolover's premises Yes No 27.DESCRIBE NATURE OF INJURY OR ILLNESS IN DETAIL,BE SPECIFIC(include pert(sl of dy affected,e.g.amputation of tight index finger a nd joint.fracturedprm,lead poisoning) �,4g_ P l�A, .A. i ,'A.c , a //c9r�uii Z�i1 '�` 't 5.E 07 7 44YS rlrn 5 'di 1v �rA2 1-c ,54 ea/ 'l.eg# ( (.''�c'79 1 �jvnr#rE s is /rrt /9/1.Mr 28.DESCRIBE EMPLOYEE'S ACTIVITIES WHEN INJURY OCCURRED WITH DETAILS OF HOW EVENT OCCURRED (include name of that innndddividuale involved,tools,machinery,o jeccty,jjpor, chemicals,radiations unnatural motions of emolovee f�•�/- .,r .4�_,/ f pit s ., _,- Ci,,,f 'y 9�/ //7�' 29. YSICIAN (full na ,title,address and phone number) 30.HOSPITAUCUNIC(name and address) Wi--- -- '--. 31.Witness and phone number. EMPLq YER 32.Legal name&mailing address incl.zip 34.Unemploy ID No.: uAK PARR, HEIGHTS 33.Date form completed: ,/j3j2/ „x---- 14168 57TH STREET. BOX 2007 STILLWATER MN 55082 35.SIC code Payroll Class Code 36. Print supervisor's name and phone number. 37.Employer's Representative,print full name,title and phone number inVonne u1; O- 39-lr39 SEND REPORT IMMEDIATELY - DO NOT WAIT FOR DOCTOR'S REPORT CONTAINS ALL ITEMS REQUIRED BY OSHA FORM 101 EMPLOYER STOP HERE-DO NOT USE THIS SPACE N P S T OCC INSURANCE 38.CARRIER 39.Insurer ID No: 40.ADJUSTER N/A Berkley Administrators SELF- D INSURE 41.Insurance Class Code: P.O. Box 59143 Mpls., MN 55459-0143 (612) 544-0311 43.Data insurer received notice: 42.CARRIER CLAIM NUMBER 02_000 729 44.Adjuster ID No: 069$639002 1.1-20320-06(1.021 Original to Berkley Administrators BA 251 S/I (4/92) Copies to Employer, Employee and Workers' Compensation Division 'th Work BILLING DATE EMPLOYER NO. PATIENT I.O.NO. PAGE Occupational Medicine Centers ( d ` A ' ��r �a4 ( 1' ��000 0 t 7. rem t 1< O EMPLOYER ' CITY OF OAK PARK HEIGHTS AS I9 ON 14168 NORTH 57TH OAK HEIGHTS PARK, MN 55082 CITY OF OAK PARK HEIGHTS j J / REMIT TO ' CITY TY t71= (JA{�. T='AhN, HEIGHTS HEALTHWORKS OCCUPATIONAL MEDICINE CENTERS \ 14168 NORTH 57TH OAK HEIGHTS PARK, M, 55082 3033 UNIVERSITY AVENUE S.E. MINNEAPOLIS,MINNESOTA 55414-3380 (612)379-7244 TAX ID#41-1558621 IMPORTANT PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENI L J HAI/\N(:I I)UI I'l\YMI HI URN H IN I $68" 71111111111110 P. KLING DATE PATIENT NAME _ PATIENT I . SOCIAL SECURITY NO. 07/31/94 BUTLER. JIMMEY A. 077370 474°•52--91)08 1 i °.1 ,::u , nut n■ r,, I I,I 'It∎N i Injury Date. 07/14/94 1st Seen : 07/29/94 Diagnosis: 840. 9 -.. SPRAIN/STRAIN SH. /UP.ARM, NOS 07/29/94 99202 NEW PATIENT VISIT LEVEL 2 ( JJ/02 ) 67. 14 07/29/94 RECORX)S/ MEDICAL RECORDS-WC/PAGE ( JJ/02 ) 1. 50 2 PAGES 07/29/94 TAX SALES TAX / MEDICAL RECORDS ( JJ/02 ) 0. 10 07/29/94 01201 PROVIDER ENCOUNTER-IN CLINIC ( JJ/02 ) CIMPI, OF ► FA' F I TIT UM 07.4 4 DIE, 1 03 :D IN 1 ,M OF ..... DATE -r ' SIGNATURE ,000x0 PLEASE REMIT PINK COPY OF STATEMENT WITH PAYMENT. PAEAN( I DUE 68. 74 0.00 0. 00 0. 00 0.0 68. 74 , , , HP,., LIVE H 3;) DVI I2 OH LIVE fi HO OVER 120 EMPLOYER'S COPY HWO16P BILLING DATE EMPLOYER NO. PATIENT ID.NO. PAGE ø7/ r34 34 019906060 07737@*.1 9 EMPLOYER CITY OF OAK PARK HEIGHTS 1416:.:‘ NORTH 57TH OAK HEIGHTS PARK MN 5508,- r- CITY OF OAK PARK HEIGHTS REMIT TO HEALTH WORKS OCCUPATIONAL MEDICINE CENTERS 141.68 NORTH 57TH 3033 UNIVERSITY AVENUE S.E. /111° OAKHEIGHTS PARK, MN 55082 MINNEAPOLIS,MINNESOTA 55414-3380 (612)379-7244 TAX ID#41-1558621 IMPORTANT PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT RAE ANCE DUE PAYME NI AN1()111\1 '‘"A $68„ 7 4 BILLING DATE PATIENT NAME PATIENT ID. SOCIAL SECURITY NO 07/31/94 BOILER, jiMNEY A. 077370 474-S2-91,08 iwo VI( ODE DE-S1R0TION CHARGES Pwe Mt N ES Injury Date: 07/14/94 1st Soen 07/2D/94 Diagnosis: 840.9 - SPRAIN/STRAIN SH. /UP. ARM, NOS 07/29/(14 99202 NEW PATIENT VISIT LEVEL 2 ( Jj/02 67_ • 07/29/)4 RECORDS/ MEDICAL RECORDS-WC/PAGE j3/02 ) - PAGES 07/29/94 TAX SALES TAX / MEDICAL RECORDS ( jJ/0 ) 0. 07/29/94 01201 PROVIDER ENCOUNTER -IN CLINIC ( Jj/02 ) a a • ' PLEASE REMIT PINK COPY OF STATEMENT WITH PAYMENT. BALANCE DUE 6 . 74 0. 0C 0. 00 0. 0 0.0t. 68.1r UPPf Ni OVER 3J OVER 60 OVER 90 OVER 120 REMIT WITH PAYMENT HWO16F Berkley Administrators a member of the Berkley Risk Management Services Group PO Box 59143 Minneapolis Minnesota 55459-0143 1612) 544-0311 Minnesota Workers ' Compensation — i oa Self-Funded Insurance Specialists • • Table of Contents I. What is Workers' Compensation? II. Who is Covered? III. What are the Benefits? IV. How to Obtain Benefits. V. Time Limitations. VI. Employer Reporting and Payment Requirements VII. Administration VIII. General Information 0 • Minnesota Workers' Compensation I. WHAT IS WORKERS' COMPENSATION Workers' Compensation Laws were passed to eliminate the "Fault" concept and the litigation brought about by the necessity of an employee proving "Fault" on the part of the employer before being able to collect benefits. Workers' Compensation Laws provide a method by which the cost of work related injuries and diseases are borne by the employer as a cost of doing business. Workers' Compensation protects both employees and employers. A covered employee who has suffered a work related injury or disease forfeits the right to sue the employer for damages and, in return, is guaranteed certain benefits. Benefits include payment of incurred medical expenses and a specific schedule for payment of disability benefits. Many employers obtain workers' compensation coverage from an insurance carrier by purchasing an insurance policy. However, other employers, through a self-funding con- cept generally called "Self-Insurance" pay benefits from their own funds. These "Self- Insurers", are subject to State Laws that insure their financial solvency and ability to pay benefits for injuries to their employees. II. WHO IS COVERED? The Minnesota Workers' Compensation Law subjects virtually all employers and employ- ees to the provisions of the Law. Some employers who are excluded include: Railroads; Family Farms; Closely Held Corporations as defined by the Law; Veterans Organizations; and Non-Profit Associa- tions. Some employees who are not subject to the Act include: Elected or Appointed Officials of the State or it's Political Subdivisions unless the Political Subdivision has passed a resolution or ordinance specifically including those officials as covered employees; house- hold workers such as domestics, grounds keepers or maintenance workers; casual work- ers, and many unpaid volunteers. Certain classes of "Volunteer" workers such as Volunteer Firefighters are covered by the Law. In some instances, employers or employees who are otherwise excluded by the law may choose to be covered or, by purchasing a workers' compensation liability insurance policy, make themselves subject to the provisions of the Law. III. WHAT ARE THE BENEFITS? A. Medical - The employer (or insurance carrier) must furnish necessary First Aid, Medical, Surgical, Chiropractic and Hospital Services, including artificial members and prosthetic devices, Repair or replacement of prosthetic devices, hearing aids, eye glasses, contact lenses, and dentures must also be paid for if the item is damaged or destroyed in a work related accident which caused injury to the employee. There is no dollar or time limit on medical benefits. However, the cost incurred must be reasonable and the provision of the medical service must have 1. • • been necessary based on the nature and extent of the injury. A maximum fee schedule for medical services has been developed and implemented by the Minnesota Workers' Compensation Division. The employer has the right to request that the employee be examined by a physician of the employers choosing at any reasonable time. If an employee, being treated by one physician, desires to change to another physician, the employee must obtain the permission of the employer, the insurance carrier, or the Minnesota Workers' Compensation Division before doing so. Failure to obtain permission to change physicians can result in non-payment of any costs incurred. An employer is responsible for the cost of surgical treatment when it is reasonably required to cure and relieve the effects of a work related injury or disease. At the employer's expense, either the employee or employer may require a second opinion on the necessity of surgery, but failure of the employee to obtain such an opinion does not relieve the employer of responsibility for payment. Travel, lodging and meal costs incurred as a result of obtaining necessary medical treatment are also compensable. Mileage expenses are reimbursed at the same rate as that used by the employer for purposes of employee expense reimbursement subject to a maximum of 27 cents per mile. Any other costs for which the employee seeks reimbursement must be reasonable and necessary. An employee who has doubt as to whether an anticipated cost will be reimbursed should consult with the employer, insurance carrier or administrator prior to incurring the expense. B. Disability Benefits - Various types of disability benefits are payable under the Law depending upon the nature of the disability. 1. Temporary Total Disability- An employee who has been injured in the course of employment is eligible for temporary total disability benefits during the period the employee is certified by a physician as being unable to work because of the nature and extent of the injury. A waiting period of 3 calendar days must first be met. If a disability extends beyond 3 calendar days, temporary total disability benefits are paid for those scheduled work days lost after the 3rd calendar day. If the disability extends for 10 calendar days or more, any scheduled work days lost during the 3 day waiting period are also compensated. Payments of temporary total disability are to continue until the employee has been released to return to regular employment or to some form of transitional employment offered by the employer or until the employee has I reached maximum medical improvement and a determination of the amount of impairment compensation or economic recovery compensation due to the employee has been made. See paragraph III D.) of this section for information regarding the level of temporary total disability benefits payable. 2. Temporary Partial Disability - Under certain circumstances, if an employee returns to limited or part time work and, as a result, suffers a reduction in usual earnings, the employee may be entitled to temporary partial disability benefits. These benefits are computed on the basis of 2/3 of the difference between the wage prior to the injury and the wage being earned in the partially disabled condition. The weekly amount payable cannot exceed the amounts set forth in paragraph III D.) Other limitations as to length of time payable may also apply. 2. • S 3. Permanent Partial Disability - If the injury results in loss of or loss of use of a bodily part or member, the employee may be entitled to permanent partial disability benefits in the form of either impairment compensation or economic recovery compensation. This section of the Law was extensively amended by the 1983 Minnesota Legislature. The Commissioner of Labor and Industry has promulgated rules to facilitate administration of this section of the Law. These rules became effective January 1, 1984 and have since been extensively ijrevised. 4. Permanent Total Disability - An employee who is totally and permanently disabled from any form of sustained gainful employment may, under certain circumstances, be entitled to compensation at the weekly rate for which the employee is qualified as indicated by paragraph III D.) during the entire period of the employee's disability. In some cases, these benefits may be coordinated with benefits received under a government disability benefits program. 5. Rehabilitation - An employee who suffers a back injury causing more than 30 days loss of time or any other type of injury causing more than 60 days loss of fI time is eligible for physical and vocational rehabilitation services designed to speed the employees recovery from the injury and to assist the employee in returning to suitable, substantial and gainful employment at the earliest possible date. Employees eligible for rehabilitation services can expect their employer or insurance carrier to refer them to a Qualified Rehabilitation Consultant who will meet with them, explain the provisions of the rehabilitation section of the Minnesota Workers' Compensation Law, the obligations of the employer, the obligations of the employee, and to work with the employee and others in developing a comprehensive rehabilitation plan. C. Death Benefits - If a work related injury causes death, compensation is payable to the employees' dependent spouse and children at a rate subject to the maximum indicated in paragraph III D.) but which may also be somewhat less depending upon the wage received at the time of the injury and the number of dependents. In the case of a dependent spouse alone, benefits are payable for a maximum of 10 years. If the deceased employee leaves a dependent spouse and dependent children, benefits are payable to the spouse and children until the children are no longer dependent under the provisions of the Workers' Compensation Law and then, to the dependent spouse for 10 more years. A maximum amount of $2,500.00 is payable towards burial expenses. D. Rate of compensation For Injuries Occurring On or After October 1, 1991 - The Weekly compensation benefit is 2/3 of the employee's weekly wage up to a maximum of $443.00 per week. Employees earning between $221.50 and $332.25 will receive $221.50 per week (50% of the Statewide Average Weekly Wage) and employees earning up to $221.50 will receive their actual gross wage but, in no event, less than $88.60. The maximum rate payable in weekly wofkers' compensation benefits is tied to the Statewide Average Weekly Wage and under the provisions of the Workers' Compensation Law, is adjusted each October 1st. 3. I IV. HOW TO OBTAIN BENEFITS Immediately following occurrence of an injury, or as soon thereafter as the employee obtains knowledge that a medical condition or occupational disease may be due to employment activity, the employee should give notice of the injury to the employees supervisor or other individual designated by the employer to receive reports of work related injuries. Notice may be given either orally or in writing. No compensation benefits are payable until after proper notice is given to the employer. Therefore, it is in the best interest of the employee to report all injuries as soon as possible. In come instances, the Law allows up to 180 days following the employees obtaining knowledge that an injury or disease might be related to employment, to report the injury or disease to the employer. However, any late reported injury or disease may be questioned by the employer based on the fact of lateness of reporting alone and therefore employees are urged to give notice to the employer in all cases, as soon as possible. V. TIME LIMITATIONS Any legal action to recover compensation must be filed with the Minnesota Workers' Compensation Division by the employee within 3 years after the employer has made a written report of the injury to the Workers' Compensation Division but not to exceed 6 years from the date of the accident. In death cases, any action by dependents to recover compensation must be filed within 3 years after receipt by the Workers' Compensation Division of written notice of the death, given by the employer, but not to exceed 6 years from the date of injury. In case an employee or dependent is physically or mentally incapable of taking the necessary action within the time specified, the time limitation is extended to 3 years beyond the point at which the incapability ceases. VI. EMPLOYER REPORTING AND PAYMENT REQUIREMENTS The employer is required to report all employee injuries involving more than 3 calendar days of lost time to the Minnesota Workers' Compensation Division. Generally, this is done by the employers insurance carrier or self-insured administrator. Within 14 days of the employer obtaining knowledge of or receiving notice of an injury which causes lost time in excess of 3 days, the employer is required to begin payment of disability benefits or to file a formal denial of liability with the Workers' Compensation Division. See "Time Limitations" above. A VII. ADMINISTRATION The Workers' Compensation Act is administered by the Workers' Compensation Division of the Department of Labor and Industry, 443 Lafayette Road, St. Paul, Minnesota 55155. The telephone number is 296-2432. Callers from outside the Twin City area can dial 1-800-652-9747 and ask for the Workers' Compensation Hot Line. In addition to receiving copies of First Reports of Injury involving disability beyond 3 days, the Workers' Compensation Division also requires filing of other specific information including certain medical reports, denials of liability, first payment receipts, etc. The 1983 changes in the Minnesota Workers' Compensation Law greatly enlarged the duties 4. • and authority of the Commissioner of the Department of Labor and Industry relative to administration of workers' compensation claims. Unfortunately, the operational structure required within the Workers' Compensation Division by those changes proved to be cumbersome. In 1987, the Law was again amended with a goal of streamlining the structure into a "singletrack" system. The Division is now reorganized to accommodate this new system of conferences and the informal methods designed to facilitate early resolution of issues and disagreements. . VIII. GENERAL INFORMATION If any employee has any question about their rights or obligations under the Minnesota Workers' Compensation Law not covered by this booklet, they are urged to first contact • someone in authority with their employer in hopes of obtaining the necessary information. In the alternative, the staff of Berkley Administrators will be happy to attempt to answer any questions that an employee or employer has on an active workers' compensation claim. Additionally, the staff of the Minnesota Workers' Compensation Division at the address and telephone number given earlier is available to any interested party to answer any questions of a general or specific nature. This Summary of the basic provisions of the Minnesota Workers' Compensation Law has been prepared by Berkley ) Administrators. The information contained in this booklet is general in nature. Space limitations require that the informa- tion not be all encompassing. Changes in the law or the specific factors of a case may result in interpretations or results different from those presented in this booklet. Information contained in this booklet is current as of March 1 , 1992. 5. • Berkley Administrators formerly EBA a member of the Berkley Risk Management Services Group PO Box 59143 Minneapolis MN 55459-0143 Phone (612) 544-0311 Ronald M. Holbach, CPCU Vice-President Self-Funded Insurance Specialists BA 003 (3/92) • • Berkley Administrators a member of the Berkley Risk Management Services Group 8441 Wayzata Boulevard PO Box 59143 Minneapolis Minnesota 55459-0143 (612) 544-0311 August 19, 1994 IITfl Oak Park Heights - IF- . P.O. Box 2007 LC AUG ? Z1991 Oak Park Heights, MN 55082-2007 Attn: La-Vonne Wilson CITY OF OAK PARK HEIGHTS I will be in your area on August 29, 1994 P.M. to audit cities participating in the League of Minnesota Cities Insurance Trust Self-Insured Workers' Compensation Program. The purpose of the audit will be to determine any balance of premium that may be refundable to or due from you. In order to complete the audit in a manner fair and equitable to all cities participating in the program, the League of Minnesota Cities Insurance Trust has directed us to examine certain records of all participating cities. Your city's period of participation was 7-07-93 to 7-07-94 Please make the following records available to me covering that period of time. 1. Payroll Journals or Registers s ■ 2. Individual Earnings Records v 3. Federal 941 and Minnesota Department of Jobs and Training Quarterly Returns 4. General Ledger 5. Cash Disbursements Journal or Checkbook /6. Contracts for services along with certificates of insurance from vendors 7. Fire contracts with other cities and townships 8. A copy of the resolution or ordinance providing WC coverage for elected or appointed officials. PY P g g PP rip+ 9. Police and Fire Department Non-Smoker Statements if, 10. Summary of Worker Hours for Volunteer Ambulance, Police Reserves, 1st Responders/ Rescue Squad Please call us if someone from y our office will not be available on the above scheduled date. Sincerely, Jeff Koschmeder Auditor Se/f-Funded Insurance Specialists BA 522 (10/91) • 202 MAYOR AND COUNCILMEN SALARIES WORKMAN' S COMPENSATION AN ORDINANCE PROVIDING FOR WORKMAN ' S COMPENSATION BENEFITS AND ESTABLISHING THE SALARIES OF THE MAYOR AND COUNCILMEN OF THE CITY OF OAK PARK HEIGHTS, WASHINGTON COUNTY, MINNESOTA. THE CITY COUNCIL OF THE CITY OF OAK PARK HEIGHTS, WASHINGTON COUNTY, MINNESOTA DOES ORDAIN: 202 .01 Workman' s Compensation. The Mayor and Councilmen of the City of Oak Park Heights are hereby entitled to receive compensation from the City in accordance with the provisions of the Workman' s Compensation Law of the State of Minnesota. If the Mayor or any Councilman sustains an injury or illness , covered by law, not caused by his intoxication or willful misconduct and not intentionally self- inflicted, which with or without negligence is proximately caused by and arises out of and in the course of performance of his duties as such Mayor or Councilman, he or his dependents shall be entitled to the maximum benefits provided under the compensation law upon the date of such injury or illness. 202 .02 Salaries. Commencing on the first business day of January, 1989 , the salary of the Mayor of the City of Oak Park Heights shall be Two. Hundred Fifty ($250 .00) Dollars per month, and the salaries of Council members shall be Two Hundred ($200 .00) per month. 202 .03 Effective Date. This ordinance shall be in full force and effect from and after its passage and publication as provided by law. City Clerk Mayor ! . • ,_)_/ / , -- - ---* 42- - - , . ,, 1 / 1'� „..,.:.,:.::::::.:::„.:::::,..:..::::::.:::.,:::„... . . , .. . 62 STATEMENT STILLWATER CLINIC, P.A. CLINIC HOURS ARE 7:00 AM - 5:00 PM 1500 CURVE CREST BLVD APPOINTMENT PHONE NUMBER 439-2072 STILLWATER MN 55082 BUSINESS OFFICE PHONE 439-1233 BETWEEN HOURS 1 :00 8 5:00 0050—O1 WCS SHOW AMOUNT $ PAID HERE 612 439-1233 08/06/94 900012525 1 110.85 OFFICE PHONE NUMBER CLOSING DATE YOUR ACCOUNT NUMBER PAGE NO. NEW BALANCE ANDERSON, KENNETH STILLWATER CLINIC, P.A. 14055 54TH ST NO 1500 CURVE CREST BLVD STILLWATER MN 55082 STILLWATER MN 55082 111111111111 iwI„1,„LLi i 11111J1„1111111J,II,i,1,1III NOTE: Charges and payments not appearing on this statement will appear on next month's statement. RETURN THIS PORTION WITH PAYMENT CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT o� o CHARGES PAYMENTS DATE PATIENT NAME/ CPT4 ICD-9 DOCTOR AND AND gy EXPLANATION OF ACTIVITY IP CODE moo CODE NAME I DEBITS ( CREDITS t', I J c l r _ 1 r l I il t t PROVIDER NOACBS 5664151 t- D-iu 41-16d5106 LAB 411683126 A STATEMENT HAS nttN SENI IU YuUR EMPLOYER FOR rAYrIENT. YOU - WILL CONTINUE TO BE BILLED UNTIL ACCOUNT IS PAID. IF NO R PAYMENT HAS BEEN RECEIVED WITHIN 60 DAYS, PLEASE CONTACT M YOUR EMPLOYER FOR AN EXPLANATION. THANK YOU! A THE STATE OF MN HAS IMPOSED A 2% TAX ON OUR REVENUES AS • R HEALTH CARE PROVIDERS WHICH WE PAY DIRECTLY TO THE STATE OF ”' K MINNESOTA. THAT 2% TAX IS REFLECTED IN OUR FEES. STATEMENT CLOSING DATE ITB/lT61g4 PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE:9UUU1C5Z5 PREVIOUS PAYMENTS& NEW .:;;BALANCE OVER BALANCE OVER BALANCE OVER BALANCE OVER NEW BALANCE BALANCE CREDITS CHARGES a 30 DAYS 60 DAYS 90 DAYS 120 DAYS PAY THIS AMOUNT 109.75 .00 .00 .00 .00 109.75 1.10 110.85 - F 1 NANGt GHAKBI is computed by a"PERIODIC RATE°of 1•U %PER STILLWATER CLINIC, P.A. MONTH (ANNUAL PERCENTAGE RATE 12.0 %)on balances 90 days and older 1500 CURVE CREST BLVD after FaINANCEcCHAaRGEng on this statement.75 been applied. Amount 110 s85ct to $ Pa y$ STILLWATER MN 55082 by 8-31-94toavoidadditional FINANCE CHARGE 61Z 4+39-1133 Fs 0 Z w r.LC1 cc Li, a JLn • 1- ~ z 1-- Zp H^ ON `f Z W w0p 2 OS • E o f W gaw N as a c0� Q.N .-4 a W Y m •O 11 m� .....='..i. i o0 N. �° >- 1- pa. U - y N 3 F o1O a H 00 QQ -1 1w� ONM W Q N a. 1- ^A O za o •• I M Z • A CO 1n N - o t110NN 0_ >O S DIN- ¢ O o. Z M.-1 JL1) O ¢Zm Ch w O gO .,,W I �• Cam aaw -'o L p> - m 00 OS (.) 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Paul, MN 55126-8044 )RKERS COMPENSATION MANAGED CARE : c rut mAye-Nwy4/0 It's Worth Considering TO: LMCIT Member Cities and Agents FROM: Tom Grundhoefer, LMCIT Senior Staff Counsel N 1EL .' , �rIJJ1C - SHOULD YOUR CITY CONSIDER MANAGED CARE? YES!! Can a city afford not to at least look at managed care? It will immediately reduce your city's LMCIT workers compensation premium by way of a five percent premium credit. If managed care is added during the coverage year, the credit is pro- rated. The five percent credit is given at each annual renewal and comes off the city's bottom line workers compensation premium. Over the past year and one-half we have communicated with cities in several different ways about workers compensation managed care. So far, 25 cities have entered into managed care agreements. A number of other cities are considering managed-care. Currently, there are eleven state-certified managed care organizations which offer managed care plans. A city may work with the managed care provider of its choice. We stress that managed care is not mandatory and is simply an option for cities to consider. At the annual conference, LMCIT staff will be available to discuss managed care with any interested city. LMCIT will have a booth in the exhibitors hall that city officials are encouraged to visit during the conference. Also, for cities not attending the conference, we simply wanted to give you another chance to think about the subject. ASIDE FROM THE FIVE PERCENT PREMIUM CREDIT, WHY IS MANAGED CARE A GOOD IDEA? Because it can reduce workers compensation medical costs and help injured workers get back to work sooner. The following outlines the ways managed care can save money and help workers. AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER (612)490-5600 1-800-925-1122 plus your city code TDD(612)490-9038 Fax(612)490-0072 • • LMCIT Member Cities Page 2 June 3, 1994 Experienced Health Provider Network Managed care channels injured workers into a system of experienced workers compensation health care providers. The managed care organization is better able to assure necessary and appropriate plans of treatment by working with health care providers who are experienced in treating workers' compensation injuries. They can also keep network health care providers up to date on changes and trends applicable to workers compensation treatment. Medical Utilization Management Through use of a trained care manager, every injured employee's claim is managed to encourage the appropriate use of medical services and facilities. This will improve quality of care and maintain cost effectiveness on a case-by-case basis. The objectives of managed care and medical utilization management are four fold: * To provide the knowledge and tools required to appropriately manage the employees medical care at the point the employee first comes into the workers compensation system * To evaluate each episode of medical care and address the procedural necessity and eliminate settings that seem questionable * Manage standard of care and present the most efficient and effective plan of treatment * Channel injured employees into the most appropriate network Active Case Management Certainly from both the employer's and employee's perspective, the ultimate goal of treating any workers compensation injury is to bring the injured worker back into the work force if at all possible. To that end, care managers work with the injured worker, their family, and their treatment provider to: * Arrange for alternative treatment when necessary * Support and encourage return to work efforts with the employee and employer r - I LMCIT Member Cities Page 3 June 3, 1994 * Arrange for physical rehabilitation services * Arrange for needed supplies or equipment * Educate injured workers and their families * Facilitate employee's return to work. Monitor primary duties and consult with employer about increased workload and/or the lifting of weight restrictions * Coordinate vocational counselling Case managers also serve as advocates for the injured worker by acting as a liaison between 1) the employer and the employee, 2) the employee and his/her medical provider, 3) the employee and the LMCIT claims staff, 5) the medical providers and the claims staff. Review of Medical Bills A final cost savings factor associated with managed care involves ongoing review of medical bills submitted by medical providers. This ongoing review assures that only those tests and treatments which are pre-authorized and/or medically necessary will be recommended for payment. WHAT COSTS ARE INVOLVED? It varies among the companies supplying managed care services. Some managed care plans charge only for specific services when an injury has occured. Others simply charge on a flat monthly or per-employee basis. For those companies that charge on a per-claim basis, the costs are simply made part of the claim that LMCIT pays. When the managed care fees are paid as part of the claim cost, they are treated like any other charge and are included for purposes of meeting the city's deductible and calculating subsequent years' experience modification. However, LMCIT believes that if managed care works as it is supposed to, it will more than pay for itself through favorable claims experience and reduced premiums. For companies charging on a monthly or per capita basis, the flat monthly or per- capita charges are billed by the managed care organization and paid directly by the City. • • • • • LMCIT Member Cities Page 4 June 3, 1994 DOES IT REALLY WORK? It's really too early to say for sure since business and government have had only a limited time to monitor its effectiveness. However, for at least two Minnesota e , the results it is prom benefit. The Minnesota mployers Department initial of Employee suggest Relations providing estimates its that ised during the first nine months of the program (July 1, 1993 to March 31, 1994) it saved $1 million compared with workers compensation costs for the same period during the previous year. This was after paying the managed care fees. The Hormel Company has had managed care in place since October 1993. They believe "without a doubt" that managed care has saved them significant money by managing medical utilization and helping to get employees back to work. I'M INTERESTED, NOW WHAT? Talk with your agent or speak with Kermine Bender or me at the League's annual conference (we will be available at LMCIT's information booth in the exhibit hall on Wednesday, June 8 or Thursday, June 9). You can also call Kermine or me directly. Kermine Bender can be reached at Berkley Administrators, (612) 591-7408. I can be reached at the League offices, (612) 490-5600. t `r 11 "We,A, i ,rAZ 31-1 )Iy4 preferred WorkCare Workers' Compensation Managed Care. July 6, 1994 Judy Hoist City of Oak Park Heights P.O. Box 2007 Oak Park Heights, MN 55082 Dear Ms. Hoist: Thank you for your request for information about Preferred WorkCare, the certified workers' compensation managed care organization of PreferredOne. I have enclosed information for your review which describes our program and services and our provider network. We also have available a variety of employer/employee educational materials and a newsletter, which we provide as a part of the enrollment process in the Preferred WorkCare program. Pricing for our services varies depending on the needs of the payer and may be based on a per claim service fee, a flat-rate per employee per month fee or a per service fee. Depending on the needs of the payer, we are willing to explore modifying both our full continuum of services, which is described in the attached information, as well as our pricing structure for those services. I would be happy to meet with you in the near future to discuss our services and pricing structure, as well as to explore how our program could meet your needs. I will call you sometime within the next week to discuss this matter further. Thank you again for your interest. Should you have any questions or need any additional information, please do not hesitate to contact me at (612) 372-3268. Sincerely, fi(4iet Mary Kay Za aria Director cc: D. C. Olsen P.O. Box 1660 • MINNEAPOLIS, MINNESOTA • 55440-1660 612/331-0270 • FAX 612/623-1997 "Equal Opportunity/Affirmative Action Employer" • Preferred WorkCare The Workers'Compensation Certified Managed Care Organization of PreferredOne Executive Summary (continued) Working with Providers...(cont'd.) medical monitoring process.They provide care for work-related injuries and illnesses based on Preferred WorkCare's established medical treatment guidelines which include those developed by the Minnesota Department of Labor and Industry.These guidelines assist providers in delivering care which is medically necessary,appropriate and effective and which focuses on timely return-to-work. Preferred WorkCare's provider network includes primary care and specialty pr widers in both the Twin Cities metropolitan and Greater Minnesota areas. The Preferred WorkCare provider network represents a subset of the larger PPO network (5000-plus providers), and has been established by choosing select providers who demonstrate a willingness to work as partners with employers, insurers and us to more effectively manage workers' compensation costs. Preferred WorkCare's providers have been selected based on their worker's compensation experience, our geographic and specialty need and the successful completion of our application, credentialing and on-site review processes. We continue efforts to expand our network to include a full complement of primary care and specialty providers in both the Twin Cities metropolitan and greater Minnesota areas. In addition to working with established network providers, Preferred WorkCare also works with out-of-network providers,educating them and monitoring their care.Our experience has shown that injured employees often choose to treat with a personal provider outside the network,as allowed under Minnesota's Workers'Compensation Managed Care Rules.Educating out-of-network providers and monitoring their care is critical to the success of controlling the costs of workers'compensation claims. Managing Cases and Reviewing Bills... PWC provides a variety of utilization management services including concurrent medical case management, preauthorization for select services and retrospective bill review as important aspects of containing workers' compensation medical and indemnity costs. Occupational health nurses work closely with providers,employers and claim representatives to facilitate timely medical intervention and early return-to-work. In addition, they review all provider bills and supporting medical documentation to ensure that treatment is medically appropriate,necessary and effective,and in compliance with PWC's established treatment guidelines.These services are provided to monitor the care of PWC network and approved out-of-network providers,as well. Summary... Preferred WorkCare provides services based on our experience in managing and responding to the challenges and opportunities of workers'compensation managed care. We know where many of the real challenges and weaknesses lie in the current systems. We have learned how to overcome obstacles and most importantly, how to work successfully in partnership with others to accomplish common goals. We offer a program and services which have been fine-tuned based on our experience, a flexible operating style and a strong commitment to serve payers, employers and employees in a manner which will effectively meet their needs. Preferred Work Care P.O. Box 1660 Minneapolis, MN 55440-1660 Tel:(612)331-0270 (800)452-7289 ext.270 FAX (612) 623-1997 April 1994 r • • • . Preferred WorkCare The Workers'Compensation Certified Managed Care Organization of PreferredOne Executive Summary Preferred WorkCare(PWC) is the certified workers' compensation managed care organization of PreferredOne, the upper Midwest's leading preferred provider organization (PPO) which began in 1984. In 1991, building on the PPO's group medical experience and success as a managed care organization, Preferred WorkCare began providing workers' compensation managed care services for employers. This early intervention with insurers, providers and employers has provided the organization a broad awareness of the issues involved in managing both the medical and indemnity costs of workers' compensation claims. Since its inception, Preferred WorkCare has assisted insurers, providers and employers in their understanding of the workers'compensation system and the impact of managed care. Over the past three years, the combined staffs of PreferredOne and Preferred WorkCare have gained experience in working through the challenges of managed care. Preferred WorkCare was certified as a Managed Care Organization (MCO) for workers' compensation by the Minnesota Department of Labor and Industry on December 16, 1992. The Preferred WorkCare program applies the principles of managed care to workers' compensation while helping the employer better manage safety and health risks. The key components of the program include a select, credentialed provider network, utilization management (medical case management and bill review in accord with medical treatment guidelines),employer/employee support and education,out-of-network provider monitoring,and provider education and support. Each of these components is supported through professional staff, operating systems, policies and procedures and management information systems which are integrated between Preferred WorkCare and the PreferredOne PPO. Preferred WorkCare currently provides managed care services for a number of insurers and self-insured employers and has enrolled over 3,000 employers in the program. Preferred WorkCare uses a flexible approach to managed care which has resulted in several successful models to implement and coordinate services with customers. Each model demonstrates active and ongoing participation of employers,providers,carriers and employees working together with Preferred WorkCare through all stages of program implementation. The following information addresses some of what Preferred WorkCare has learned and generally describes why the organization is well-suited to meet the workers'compensation managed care needs of employers and insurers. Working with Insurers... Preferred WorkCare has established contractual relationships with workers'compensation insurance carriers and self- insured employers who are dedicated to more effectively controlling the costs of workers' compensation claims through managed care. Our experience has given us the opportunity to successfully implement managed care in "partnership"with a variety of organizations and players. Working with Employers... Employers know the costs associated with workers' compensation better than anyone else; they write the premium checks, and they realize the need to better manage their costs. Educating these employers on the best ways to manage their costs has been one of our primary tasks. PWC believes that employers need to understand and work with managed care on the"home front," in order to effectively control the cost of workers'compensation claims. We have developed tailored materials and methods for educating employers and employees to enroll them in the PWC program and to guide them through the managed care process from the point of injury to closure. Working with Providers... A qualified and well-managed provider network is the keystone of a quality managed care organization. Preferred WorkCare makes available and manages a select network of providers who demonstrate an understanding of the workers' compensation system and the associated challenges in managing medical and indemnity costs of a work- related claim. The Preferred WorkCare providers are sensitive to the philosophy of occupational health and the • Preferred WorkCare The Workers'Compensation Certified _ Managed Care Organization of PreferredOne Program Services Preferred WorkCare(PWC) offers an integrated continuum of workers' compensation managed care services. Based on the unique needs of the payer, these services can be purchased in a fully-integrated (bundled) or select service (unbundled) manner, based on flexible pricing. The key components of the program are described below. ** Certified Managed Care Plan: Preferred WorkCare is certified as a managed care organization (MCO) by the Minnesota Department of Labor and Industry. As a certified MCO, Preferred WorkCare offers the employer the opportunity to direct injured employees to receive care from a select network of providers whose treatment is monitored to ensure that it is medically necessary, appropriate and effective, and focused on timely return to work. As a result. employers should realize a reduction in both the medical and indemnity costs associated with a workers'compensation claim. ** Provider Network: Employees and employers have access to a select network of providers to receive treatment which is medically necessary, appropriate and effective and which focuses on timely return-to-work.The network includes physicians, hospitals, chiropractors, urgent care centers, and other health care professionals who deliver services based on PWC's established medical treatment guidelines and reporting requirements. These providers are located in both the Twin Cities metropolitan and Greater Minnesota areas and are selected based on specialty and geographic need, experience in workers' compensation,and successful completion of PWC's provider application,credentialing and on-site review processes. ** Medical Treatment Guidelines: Preferred WorkCare has developed a number of medical and surgical treatment guidelines which establish parameters for the appropriate treatment of workers' compensation injuries. These guidelines incorporate the Treatment Parameters established by the Minnesota Department of Labor and Industry. PWC's guidelines are established and continually reviewed, through consensus,by an internal Medical Services Review Committee of occupational health professionals.The guidelines are developed specifically for work-related injuries and illnesses,and are based on available scientific data and community standards of care. ** Employer Enrollment: Managed care in workers' compensation requires that employers be educated and enrolled in Preferred WorkCare as a critical first step. PWC offers enrollment services for program participants in both the seven-county metropolitan and greater Minnesota areas. Payers may choose from a variety of methods, including a single employer meeting,group employer meetings or a mail/follow-up telephone call process. Meetings are conducted by professional PWC staff and coordinated with the payer to explain managed care and the Preferred WorkCare program to employer representatives. Participants receive a variety of written materials,including employee identification cards and a PWC provider directory. As needed, these materials may be copied for use in educating employees. Enrolled employers also receive the Preferred WorkCare newsletter two times per year. Employer meetings are limited to the seven county metropolitan area,however, exceptions for Greater Minnesota may be negotiated. ** Utilization Management (UM): Preferred WorkCare provides a variety of utilization management services which are primarily coordinated with the employer, provider and claim representative by the PWC medical case manager and/or utilization review nurse. The focus of Preferred WorkCare's UM services is directed toward management and review of an injured employee's medical care to ensure that treatment is medically necessary, appropriate and effective, that it focuses on timely return-to-work, and that it complies with Preferred WorkCare's medical treatment guidelines. PWC's Utilization Management services are provided to manage the medical care delivered by any PWC network or approved out-of- network treating provider, both medical and chiropractic. Throughout all stages of Utilization Management, PWC works closely with the claim representative and uses the active involvement of occupational health professionals (nurses, medical director, chiropractic director, etc.) to deliver a variety of services on a prospective, concurrent and retrospective basis. Preferred WorkCare's UM services are further described below. A . Concurrent, Telephonic Medical Case Management: Occupational health nurses review all injuries which occur on or after the employer's effective enrollment date in Preferred WorkCare, upon receipt of the First Report of Injury. As appropriate, the nurse initiates contact with the provider, and/or the employer to review the injury and the employee's medical/return-to-work status. Concurrent,telephonic medical case management focuses on medical necessity, appropriateness and effectiveness of treatment and continues until the employee reaches maximum medical improvement (MMI), when the case is closed. If a case reopens, the PWC nurse performs medical case management services,as appropriate. As an initial step in PWC's medical case management process, the nurse also verifies the employee's lkPreferred WorkCare orkers' Compensation Certified • Managed Care Organization of PreferredOne Program Services (cont'd) treating history, if treatment is initially received from an out-of-network provider. This process includes receiving telephone and written confirmation from the provider, educating an approved provider about Preferred WorkCare,reviewing the appropriate PWC medical treatment guideline(s)with the provider and forwarding a copy to him/her, and sending either a written approval or non-approval letter to both the provider and the injured employee. PWC's medical case management process does not include disability case management or vocational rehabilitation services. Rather, PWC coordinates their medical case management services closely with a disability case manager or QRC,should one be assigned to the case. B. Utilization Review (UR): Preferred WorkCare nurses provide both prospective and retrospective utilization review services. On a prospective basis, providers are required to call PWC for prior authorization of a variety of services, including non-emergency inpatient hospitalizations, out-patient surgical procedures, select medical imaging procedures, mental health and chemical dependency programs, pain programs, functional capacity evaluations and work hardening programs,select durable medical equipment and any treatment which falls outside the PWC treatment guidelines. For emergency services, providers must contact PWC within 48 hours of treatment. PWC's prior authorization process makes recommendations based only on medical appropriateness and effectiveness. Routinely,this recommendation is coordinated with the payer's determination of compensability. Any provider treating a Preferred WorkCare participant is required by PWC to send all medical bills with supporting medical documentation to PWC, prior to being reimbursed by the payer. On a retrospective basis, Preferred WorkCare registered nurses review each bill and the supporting medical documentation to ensure medical appropriateness and necessity of treatment in compliance with PWC's medical treatment guidelines,documented prior authorization, and adequacy of medical documentation. PWC forwards all reviewed bills and medicals to the payer with a topsheet and recommendations. PWC makes no determination of compensability; retrospective UR does not include formal code review or bill audit functions. UR services cover review of all bills and medicals for treatment provided up to MMI. Additional Services of Preferred WorkCare ** Appointment Scheduling: Providers must be available to accommodate an injured employee's request for a non- emergency visit within 24 hours of the request,or sooner as required for urgent and/or emergency situations. ** Referrals: Referrals to specialists and supportive services from both network and approved out-of-network primary treating providers must be made to a provider within the Preferred WorkCare network. ** Employer Support and Education: PWC is available to provide written information and in-person meetings, as needed, with employers.Improved awareness of workers'compensation issues and cooperation with managed care by employers supports early return to work and cost savings. In conjunction with insurance carriers and third-party administrators,Preferred WorkCare staff encourage and guide employers through injury case management and managed care. ** Peer Review and Dispute Resolution: PWC provides formal dispute resolution and peer review processes which any provider,employer and employee may access. Each of these processes supports Preferred WorkCare's commitment to quality service,customer satisfaction, and ongoing improvement in our program and services. ** Reporting: Preferred WorkCare makes available a variety of standard and customized reports on managed care participation. ** Quality Management: Preferred WorkCare, in conjunction with PreferredOne, has initiated a continuous quality improvement(CQI)program to ensure the delivery of high quality,effective and efficient services. * Provider Education and Support: Preferred WorkCare's professional staff work closely with both network, and approved out-of-network providers and offer a variety of services to educate them about managed care,medical treatment guidelines, occupational health principles and workers'compensation reform in general. Building"partnership"relationships with providers through education and support is a major goal of Preferred WorkCare's program. f • PREFERRED WORKC A R F The Certified Managed Care Organization for Workers'Compensation of PreferredOne Provider Checklist For Work Related Injuries Under Preferred WorkCare Minnesota law requires that ALL providers treating patients whose employer has enrolled in a certified managed care organization for workers' compensation comply with the following: 1. Treatment based on medical necessity, appropriateness and effectiveness according to treatment standards of the managed care organization, including preauthorization for certain treatments. 2. Completion of a Work Ability form for the employee after each visit, including documentation in the chart. 3. Submission of all bills on HCFA 1500 or UB-92 forms with supporting medical documentation. 4. Treatment of injured employees (non-emergency) within 24 hours of request. 5. Referrals to specialists or supportive services within the managed care network. When an employee presents at your clinic with a work-related injury, please follow these steps. If you have questions or need assistance, please call Preferred WorkCare at (612) 331-0270 or(800) 452-7289 ext 270 or fax us at (612) 623-1997. 1. Determine whether the employee is covered under a managed care organization (MCO). a) The employee might be carrying an ID card from Preferred WorkCare or another MCO. b) If the employee/employer does not know if they are enrolled with an MCO,check the list of Preferred WorkCare enrolled employers in your PWC Provider Manual. 2. If the employee is covered under Preferred WorkCare, you need to remember the following: a) The provider must fill out a Work Ability form (use Preferred WorkCare's form, the State of Minnesota form, or your clinic form if it meets the State requirements)each time he/she sees the employee. Restrictions should be written clearly to enable employers to translate them into restricted duty jobs.The form should be given to the employee to take to his/her employer, and a copy should be kept in the medical record. Mail or FAX a copy to PWC the same day as the appointment at (612) 623-1997. b) Certain services must be preauthorized 1. All hospital admissions,and surgeries in an outpatient 4. Pain programs setting or surgery center 5. Select medical imaging 2. Functional capacity evaluations,work hardening/work 6. Select durable medical equipment conditioning programs 7. Any treatment which falls outside Preferred 3. Mental health/substance abuse programs WorkCare's Treatment Guidelines All providers must obtain authorization in advance for any non-emergency service listed above. Preauthorization always requires supporting medical documentation. Emergency treatment does not require preauthorization, but the provider must notify Preferred WorkCare within 48 hours of treatment.Failure to obtain preauthorization as required may result in non-payment. Call(612)331-0270 or(800) 452-7289, ert. 270 for preauthorization. c) Providers must adhere to the treatment guidelines of Preferred WorkCare,which incorporate the State Treatment Parameters.These guidelines appear in the Provider Manual or are mailed to out-of-network providers. If treatment falls outside the guideline for a particular injury and the provider does not document the necessity for the treatment, the service may be recommended for denial of payment. d) All referrals (such as physical therapy, orthopedics, neurology) must be made into the Preferred WorkCare network. In the event of a referral,please notify the specialty provider that the employee is covered under Preferred WorkCare,and provide medical records and X-rays to the specialty provider as needed. 1. Referral providers must coordinate care and any consultation with the referring provider and Preferred WorkCare case managers. 2. Referral providers must refer back to the primary care provider if treatment is unsuccessful. e) All bills, with appropriate medical documentation attached, should be sent to: Preferred WorkCare P.O. Box 1660 Minneapolis, MN 55440-1660 July 1994 O • Preferred WorkCare The Certified Workers' Compensation Organization of PreferredOne Participating Provider X994 Directory i� 1 Table of Contents: Primary Care Evaluating and Treating Providers 1 Specialist and Supportive Providers 10 Hospitals 23 All Providers by Specialty Index 25 © 1994 PreferredOne PreferiWorkCare Provider Director. Primary Care Evaluating and Treating Providers by City f - Albany Mork Clinic Hanson Chiropractic HealthWorks 1833 2nd Avenue South 702 5th Street NW 600 West 98th St.Suite 395 :Chiropractic ' In Anoka.MV 55303 Bemidji,MN 56601 Bloomington.MV 55420 Davis Chiropractic Clinic 612-421-3680 213-751-9633 612-885-6170 Po Box 600 ,Urgent Care Family Practice Albany,MW 56307 Mork Clinic MeritCare Clinic Bemidji BIue Earth 612-845-4850 1833 2nd Avenue South 1233 34th Street NW Family Practice 1 Alexandria. Anoka.MN 55303 Bemidji.Mkt 56601 Blue Earth Medical Center 612-421-3680 218-759-5000 520 South Galbraith Chiropractic Internal Medicine Blue Earth.MV 56013 Peterson Chiropractic Aurora 507-526-7371 MeritCare Clinic Bemidji 1106 Broadw Family Practice 1233 34rh Street NW Alexandria.MW 56308 East Range Clinics-Aurora Braham Bemidji,MN 56601 i 612-762-8671 405 W 3rd Ave Family Practice :Family 218-759-5000 Practice I Aurora,MN 55705 Braham Clinic Alexandria Clinic,P.A. 218-229-3311 Blaine 112 NW 5th Street 610 Fillmore St,PD Box 1149 'Internal Medicine Family Practice Braham,MN 55006 Alexandria.MW 56308 East Range Clinics-Aurora Blaine Medical Center 612-396-3341 612-763-5123 405 W 3rd Ave 12175 Aberdeen St NE _Brainerd. Thompson,M.D.,Michael B._ Aurora.MN 55705 Blaine.MY 55434 1600 South Broadway 218-229-3311 612-785-4200 Chiropractic Alexandria MN 56308 i Crow Wing Chiropractic Internal Medicine I 612-762-23 Babbitt 220WWashington Blaine Medical Center Internal Medicine !Family Practice Brainerd 56401 12175 Aberdeen St NE 218-829-29-841.1 Alexandria Clinic,P.A. Ely Medical Center-Babbitt Blaine.MV 55434 610 Fillmore St.PO Box 1149 (Duluth Clinic) 612-785-4200 Brooklyn Center Alexandria MN 56308 45 North Drive 612-763-5123 Babbitt MW 55731 Bloomington Family Practice 218-827-2176 Northport Medical Center,Ltd Annandale' {-t Chiropractic I 5415 Brooklyn Blvd. Chiro ractic Bagley-, Lindberg Chiropractic Brooklyn Center,,41iV 55429 p Chiropractic 726 IV.98th St 612-533-8666 Family Chirp Centers Bloomington.MN 55420 25 Chestnut Street West Bagley Chiropractic 612-881-4421 Internal Medicine Annandale.MW 55302 103 Clearwater Ave No Northwestern College of Northport Medical Center,Ltd 612-271-3060 Bagley,:UV 56621 Chiropractic 5415 Brooklyn Blvd i 218-684-6253 Brooklyn Center,MV 55429 Family Practice 2501 West 84th Street Annandale Family Physicians "Family Practice Bloomington.MV 55431 612-533-8666 55 No.Maple Avenue MeritCare Clinic Bagley 612-885-5444 Brooklyn Park Annandale,MN 55302 123 Fourth Street NW Valley West Chiropractic 612-274-3744 Bagley,NV 56621 10700Normandale Blvd Chiropractic Brook Anoka 218-694-2384 Bloomington.MN 55438 Clinic West Chiropractic Bayport 612-888-5805 6800 786 Ave.N. Family Practice !Family Practice yy Mork Clinic Chiropractic 1 Brooklyn PonktblN 55445 HealthWorks 612-566-1042 1833 2nd Avenue South Wieden Chiropractic 600 West 98th St,Suite 395 Anoka.MV 55303 324 No.5th St {Family Practice Bloomington,MV 55420 Brooklyn Park Medical Center 612-421-3680 Bayport.SW 55003 612-885-6170 Internal Medicine 612-439-7621 5805 74rhAve.North i Occupational Medicine " Brooklyn Park MN 55443 Bemidji 612-572-5700 Chiropractic Internal Medicine Preferred WorkCare Primary Care Providers 21-Jun-94 1 Brooklyn Park Medical Center !Fa ractice Chanhassen Chiro.c Cold Spring 5805 74th Ave.North Oc onal Medicine- 680 W. 78th Street j - --Brooklyn Park MN 55443 Cambridge Hospital Chanhassen.MN 55317 Chiropractic 612-572-5700 725 South Dellwood 612-934-4500 First Chiro Cold Spring Occupational Medicine I Cambridge,,'IlV 55008 Family Practice 402 Red River Ave.N.#3 Brooklyn Park Medical Center 612-689-7777 Chanhassen Medical Center Cold Spring,MN 56320 5805 74th Ave.North Professional Medical Assoc 470 W. 78th St..PO Box 423 612-685-8284 Brooklyn Park AZT 55443 (Cambridge Clinic) (Internal Medicine Y Chanhassen,M V 55317 i 612-572-5700 626 SW ith.dvemte 612-934-0570 St. Cloud Medical Group- Cambridge.MIN 55008 Cold Spring Buffalo 612-689-1411 Chaska 402 M Red River Ave#2 Chiropractic l !Internal Medicine IFamily Practice Cold Spring,MN 56321 Family Chiro Centers Professional Medical Assoc Valley Family Practice 612-685-8641 110 Division Street (Cambridge Clinic) 822 Yellow Brick Rd Columbia Heights Buffalo.14V 55313 626 SW th.4venue Chaska.MW 55318 612-682-1471 Cambridge,MV 55008 612-448-3303 Chiropractic !Family Practice 612-689-1411 Heights Chiropractic Occupational Medicine Chisago City 4111 Central Ave.ME. Buffalo CIinic,P.A. p 1700 Highway 25,V. Occupational Medicine- Family Practice Columbia Heights.MN 55421 Buffalo.MN 55313 Cambridge Hospital Chisago Health Services 612-788-0515 612-682-1313 725 South Dellwood 11685 Lake Blvd.North Family Practice Buffalo Family&Specialty Cambridge,MN 55008 Chisago City,MN 55013 Columbia Park Clinic Care Center,P.A. 612489-7777 612-257-8400 4000 Central Avenue NE 303 Catlin Cannon Falls internal Medicine Columbia Heights.MW 55421 Buffalo,MV 55313 - Chisago Health Services 612-572-5700 612-682-5225 iFami/y Practice 11685 Lake Blvd North iInternal Medicine Internal Medicine Cannon Family Health Center Chisago City.MGV 55013 Columbia Park Clinic Buffalo Clinic,P.A 1122 West IOU Street 612-257-8400 4000 Central Avenue NE Cannon Falls,MN 55009 1700 Highway 25 N. Columbia Heights.MN 55421 507-263-3951 Clearbrook Buffalo,MV 55313 612-572-5'00 612-682-1313 Internal Medicine Family Practice Occupational Medicine Buffalo Family&Specialty Cannon Family Health Center MeritCare Clinic Cleat-brook Columbia Park Clinic Care Center,P.A. 1122 West Mil Street Elm Street 4000 Central Avenue NE 303 Catlin Cannon Falls,MN 55009 Clearbrook MIN 56634 Columbia Heights MV 55421 Buffalo.MN 55313 507-263-3951 218-776-312 612-572-5700 612-682-5225 Cass Lake -Clearwater Coon Rapids Burnsville'; -Y- Family Practice !Family Practice Chiropractic Chiropractic MeritCare Clinic Cass Lake St. Cloud Medical Group- Coon Rapids Chiropractic Northwestern College of RR3.Box 1 Clearwater Clinic Chiropractic Cass Lake.MN 56633 615 Nelson Drive 330 Northdale Blvd. 12445 River Ridge Road 218-335-2559 Clearwater,MN 55320 Coon Rapids.MW 55433 Burnsville,MV 5.5337 ., ;- : 612-558-2293 612-755-4300 612-894-7620 Champlin. . , . t Family Practice Family Practice Cloquet Family Practice Burnsville Family Physicians Champlin Medical Center Chiropractic Coon Rapids ookD cal Center 11269Je Jefferson Benson Chiropractic Clinic 9055 Springbrook 5 12940 Harriet Ave.South p Champlin,MT/55316 807 Cloquet Avenue Coon Rapids.MIN 55433 Burnsville,MV 55337 p q 612-780-9155 612-894-9700 612-427-9610 Cloquet,MV 55720 Internal Medicine 118.879-6049 Family Medicine Clinic Cambridge 3960 Coon Rapids Blvd Suite 100 Champlin Medical Center Cokato Coon Rapids.MV 55433 Chiropractic 11269 Jefferson Hwy. 6114114600 Cambridge Chiropractic Champlin..l1N 55316 1Family Practice 141 SW 2nd Avenue 612-427-9620 Litchfield Clinic-Cokato Internal Medicine Cambridge,'1W 55008 770 South Broadway 612-689-2462 Chanhassen+ r Cokato.MN 55321 Chiropractic 612-286-2123 Preferred WorkCare Primary Care Providers 2I-Jun-94 2 . Coon Rapids Medical Center MeritCainic Detroit Lakes !Occupational Medicin j Mork Clinic 9055 SpringbrookDr. 1245 S Wigton United Occupational Hea 330 3rd Street - Coon Rapids.,LW 55433 Detroit Lakes..LLV 56501 990 Lone Oak Road,Suite 120 Elk Rives MN 55330 - 612-780-9155 218-846-2000 Eagan.MN 55121 612-4414660 Occupational Medicine Duluth 612-452-8266 Rum River Medical Coon Rapids Medical Center 1 Associates-Elk River p IChiro ractic 'Urgent 9055 Spring brook Dr. p Urgent Care-Eagan 290 Main Street Northwest Coon Rapids..LN 55433 Fisher Chiropractic 990 Lone Oak Road Elk River,.4N 55330 612-780-9153 1118E Superior St. Eagan.LN 55121 612-241-0373 Ur ent Care Duluth,NV 55802 iiInternal Medicine 9 612-454-7809 I Urgent Care-Coon Rapids 218-728 4639 Rum River Medical Medical Ctr Family Practice Eden Prairie Associates-Elk River 9055 Springbrook Drive Duluth Clinic !Chiropractic 1 290 Main Street Northwest Coon Rapids..<5V55433 400 East 3rd St Ecklund&Ecklund Elk River.MV 55330 612-780-7000 Duluth.1W 55805 Chiropractic 612-241-0373 218-725-3156 561 Prairie Center Dr. Ellsworth Cottage Grove Duluth Clinic-Hermantown Eden Prairie.MN 55344 Family Practice 4886Miller Trunk Highway 612-943-1188 Family Practice River Valley Clinic,P.A. Duluth,.LW 55811 Family Practice I Interstate Medical Center 8451 SE Point Douglas Rd. 218-727-8119 230 Cairns Street Eden Center Family Physicians Cottage Grove,,LW 55016 Duluth Clinic-West Ellsworth,WI 54011 830 Prairie Ctr.Dr.#180 612-458-1884 4325 Grand Ave .1� 715-273-5061 Eden Prairie. V 55344 Duluth.MV 55807 611-946-0947 Internal Medicine Crookston 218-725-3513 Interstate Medical Center Chiropractic J Duluth Clinic-Lakeside Edina 230 Cairns Street Biermaier Chiropractic Clinic 4621 East Superior St (Chiropractic j Ellsworth.WI 54011 1226 University Ave..Box 496 Duluth.MN 55804 Hammond Chiropractic 715-273-5061 Crookston,ASV 56716 218-525-7487 6950 France Ave.S. Ely 218-281-6311 St. Luke's Occupational Edina,NW 55435 Crystal Health Svc. 612-922-3770 ;Family Practice 915 East First Street Family Practice Ely Medical Center(Duluth Family Practice Duluth NA'55805 • Clinic) Bass Lake Physicians 218-726-5345 Edina Family Physicians 224 East Chapman St 5203 Vernon Ave,South 5707 West Broadway Internal Medicine Edina,;1W 55436 Ely. i 55731 Crystal NW 55439 Duluth Clinic 218-365-3151 612-925-2200 612-537-6022 400 East 3rd St Occupational Medicine Eveleth Northwest Family Physicians, Duluth,MN 55805 P.A. 218-735-3156 Occupational Medicine Family Practice Consultants 5502 W.Broadway Occupational Medicine East Range Clinics-Eveleth Crystal MN 55428 p 6500 Barrie Road Suite 10 239dleKinleyAve 612-537-8475 Duluth Clinic Edina,LW 55335 Eyelet&MN 55734 400 East 3rd St 612-920-5663 218-744-3472 Deer River Duluth MV 55805 Urgent Care ! Family Practice 218-725-3156 Urgent Care-Fairview EVensvilIe Deer River Community Clinic Urgent Care Southdale Family Practice (Duluth Clinic) Urgent Care-ReadyCare St. 6401 France Ave So Evansville Clinic 1002 Comstock Drive Luke's Hospital Edina,AV 55435 109 Main Street Deer River,.LW 56636 915 East 1st.SL 612-924-5030 Evensville,AV 56326 218-246-8275 Duluth-AV 55805 218-948-2234 218-726-5555 Elk River Detroit Lakes Chiropractic Fairmont [Family Practice Eagan Rafferty Chiropractic Chiropractic MeritCare Clinic Detroit Lakes Chiropractic 653 Main Street Lund Chiropractic Clinic 1245 S.Washington Eagan Chiropractic Elk River.MN 55330 118 West Second St t Detroit Lakes,MV 56501 1565 Cliff Rd 612-441-2411 Fairmont,MV 56031 218-846-2000 Eagan.Y 55122 Family Practice 507-235-3331 Internal Medicine 612-6$8-0462 21-Ju 4 Preferred Workfare Primary Care Providers n-9 3 Fargo 1Pa tactics 1 Fridley Plaza Clini River Valley Clinic,P.A. Foley edical Center, Ltd. 6341 University Ave., 1210 W.First St. - - Chiropractic Fridley,ARV 55432 Hastings.MN 55033 400 No.Broadway ng Ihry Chiropractic Foley,ARV 56329 611-572-5710 612-438-1800 1330 Page Drive 612-968-7234 jOccupational Medicine Internal Medicine Fargo,ND 58103 Fridley Plaza Clinic River Valley Clinic, P.A. 701-232-1232 Forest Lake 6341 University Ave.NE 1210 W.First St. [Family Practice 1 ;Chiropractic Fridley..VEST 55432 Hastings.MV 55033 MeritCare Clinic North Fargo Forest Lake Chiropractic 612-572-5710 612-438-1800 2601 Broadway 591 N.Shore Drive Fargo,ND 58012 Forest Lake,ARV 55025 Glencoe Hawley 701-234-2900 612-464-2133 'Chiropractic j Family Practice MeritCare Clinic Southpointe Family Practice Gauer Chiropractic Hawley Medical Center 2400 32nd Avenue So. Ceman, M.D., Chris P. 1706E 10th St 1413 Main Fargo,ND 53104 79 N.Lake Street Glencoe,MV 55336 Hawley,.AMV 56549 701-234-8800 Forest Lake.MN 55025 612-864-3196 218-483-3564 MeritCare Clinic Southwest 612-464-7706 Family Practice 2701 13th Avenue South Hibbing Forest Lake Doctors Clinic Glencoe Medical Clinic,P.A. Fargo,ND 58103 121 SE 11th Avenue 525 18th Street East Chiropractic 701-234-3600 Forest Lake.ARV 55025 Glencoe,.V1N 55336 Vechell-Michaels Chiropractic MertiCare Broadway Health 612-464-7100 612-864-3116 115 West Howard St Centre Hibbing,MN 55746 'Internal Medicine Internal Medicine 736 Broadway 218-262-3315 Fargo.ND 58123 Forest Lake Doctors Clinic Glencoe Medical Clinic,P.A. 121 SE 11th Avenue 525 18th Street East Hillman 701-234-2000 - Forest Lake,AV 55025 Glencoe,MV 55336 internal Medicine Family Practice 612-464-7100 612-864-3116 MeritCare Clinic Southpointe Mile Lacs Family Clinic 2400 32nd Avenue So. Frederic Golden Valley 360 3rd Avenue Fargo,ND 58104 'Chiropractic Chiropractic Hillman.AV 56338 701-234-8800 Lauritsen Chiropractic Valley Square Chiropractic 612-277-3682 MeritCare Medical Group 301 Ash Street 7500 Olson Memorial Hwy. Hinckley 737Broadway Frederic.WI 54837 Golden Valley,ARV 55427 Fargo,ND 58123 715-327-4253 612-545-8600 Family Practice 701-�34-2000 Mora Medical Center- Fridley �. Family Practice Hinckley Faribault Golden Valley Clinic,Ltd. 302 Fire Monument Chiropractic 8240 Golden Valley Rd Hinckley. LW 55037 Chiropractic �'• Kramber Chiropractic Clinic Golden Valley, t0(55427 612-384-6189 Sealy-Navarro Chiropractic 1299 Mississippi St.NE 612-545-1445 127 NW 4th St Fridley,MN 55432 Hudson Faribauls.MN 55021 612-571-4148 Grand Rapids 507-334-3251 Family Practice Family Practice [ Chiropractic I Hudson Physicians, Ltd. Farmington f Fridley Medical Center Simonson Chiropractic 400 Wisconsin Street Family Practice 7576 Madison St.NE 524 NW 3rd Avenue Hudson.WI 54016 River Valley Clinic,P.A. Fridley,MV 55432 Grand Rapids.NAV 55744 715-386-8880 910 Main Street 612-785-4500 218-326-4022 Fridley Plaza Clinic •Fridley "o Farmington. W 55024 Halstad 6341 University Ave.NE ' 1FamilyPractice 612-463-7181 Fridle y, RV 55432 !Family Practice I Hugo Medical Clinic Floodwood 612-572-5710 MeritCare Clinic Halstad 14145 North Forest Blvd 'Internal Medicine 224 2nd Avenue West Hugo,ARV 55038 Family Practice Halstad ARV 56548 Floodwood Community Clinic Fridley Medical Center 612-426-9216 (Duluth Clinic) 7576,Idadison St.NE 218-456-1158 Hutchinson Floodwood SAN 55736 Fridley,MN 55432 Hastings : i 4 Chiropractic 612-785-4500 218-476-2221 612-785-4500 Practice I Foley Preferred WorkCare Primary Care Providers 21-Jun-94 4 i Kamrath Chiropractic . Medicine MinnHealth,P.A. 717 Shady Ridge Road Lake. o Mankato Clinic 1814 N.St Paul Road Hutchinson.MN 55350 Family Practice 1230 East Main St Maplewood MN 55109 - - 612-587-3888 Minniaealth,P.A. Mankato,MN 56002 612-777..0298 !Family Practice 11240 Stillwater Blvd. 507-615-1811 Lake Elmo.M1'2t 55042 'Melrose Hutchinson Medical Center, Occupational Medicine P.A. 612-777-9363 Chiropractic Mankato Clinic 3 Century Avenue Nleirose Chiropractic Lakeville 1230 East Main St p Hutchinson..1.114 55350 Mankato.MLW 56002 109 So 1st Ave West 612-587-2020 Chiropractic Melrose,MV 56352 Dakota Chiropractic Clinic 507-625-1811 Internal Medicine p 612-256-4692 17787KenwoodTrail Maple G Hutchinson Medical Center, p Grove Family Practice P.A. Lakeville.MV 55044 Chiropractic ( Melrose Clinic,P.A. 3 Century.;venue 612-435-3345 Maple Grove Family 603 West Main Street Hutchinson.. w 55360 Family Practice I Chiropractic Melrose..1,11V 56352 612-587-2020 Kenwood-Dodd Medical Clinic 13704 Grove Dr. 612-256-4228 20157 Icenic Trail Maple Grove,MV 55369 Inver Grove Heights Lakeville,MN 55044 612-420-5200 Milaca Chiropractic 612-469-3393 Family Practice Chiropractic Inver Grove Chiropractic Lester Prairie Camden Physicians, Ltd.- Fogel Chiropractic 6506 Cahill Ave. Grove Square Office 1055 Central Inver Grove Heights.MN 55075 'family Practice 13800 83rd Way ,btilaca.MV 56353 612-451-1012 Lester Prairie Medical Clinic Maple Grove.MN 55369 612-983-6805 Isle 28 Hickory Street No. 612-420-5822 1Famil y Practice Lester Prairie,MN 55354 Maple Grove Medical Center Rum River Medical Chiropractic I 612-395-2527 13986 Maple Knoll Way Associates-Milaca Mille Lacs Chiropractic Internal Medicine �p/ Maple Grove,MV 55369 150 10th Street NW,Suite B 275 West Main St Lester Prairie Medical Clinic 612-420-5700 Milaca MN 56353 Isle.MIN 56342 28 Hickory Street No. !Internal Medicine 612-983-6101 612-676-3501 Lester Prairie,MN 55354 Camden Physicians,Ltd.- Minneapolis Family Practice 612-395-2527 Grove Square Office Mile Lacs Family Clinic Litchfield 13800 83rd Way Chiropractic 360 3rd Avenue South Maple Grove,MN 55369 Calhoun Chiropractic Isle,MI 56342 ;Family Practice 612-420-5822 1620 Lake Street 612-676-3661 Litchfield Medical Clinic !Urgent Care Minneapolis.MN 55408 Jordan 611 S.Sibley Ave Urgent Care-Grove Square 612-822-5973 Litchfield MN 55355 Convenience Care Forsgren Chiropractic Family Practice 612-693-2804 13800 83rd Way 2546 Central Avenue NE Sundance Medical Clinic,Ltd. flnternal Medicine Maple Grove,MW 55369 Minneapolis,MN 55418 506W 2nd St Litchfield Medical Clinic 612-420-5279 612-781-1725 Jordan.MV 55352 611 S.Sibley Ave ,� Y. Northwestern College of 612-492-3100 LitchfLitchfield,AV 55355 Mapleton ` ` - Chiropractic ' 612-693-2804 !Family Practice 2929 Bloomington Avenue Lake City Mankato Clinic Minneapolis.MV 55407 Chiropractic Little Falls 612-721-5738 305 Main St East Lake City Chiropractic Family Practice ,1.lapieron,L@I 56002 The Cities Chiropractic Center 1275.High Family Medical Center,P.A. 507-324-3835 800 Nicollet Mall #540 Lake City,MN 55041 811 SE 2nd Street Minneapolis,MIN 55402 612-345-3361 Little Falls MN 56345 Maplewood 612-333-9144 Lake Crystal 612-632-6611 !Family Practice Family Practice MinnHealth,P.A. Camden Physicians,Ltd.- Family Practice Mankato ,- Camden Office 716 Upper AftonRoad Mankato Clinic [Family Practice Maplewood MN 55119 1206 No.42nddvenue 221 South Murphy Mankato Clinic 612-739-4599 Minneapolis,L1N 55412 Lake Crystal.MN 56002 1230 East Main St 612-522-6601 507-726-2136 Mankato,MN 56002 507-625-1811 Preferred WorkCare Primary Care Providers 21-Jun-94 5 Family Medical Clinic- Urare-Family Medical Mora Medical Cent Mankato Clinic Fairview Clinics Cli 224 Seventh St. 1875 Lookout Drive - •- 3809 42nd Ave So 2849 NE Johnson St Mora,Ml 55051 North Mankato.MN 56001 Minneapolis.IN 55406 Minneapolis.MN 55418 612-679-1313 507-625-5027 612-721-6261 612-781-9436 North Ridge Family Medicine Family Medical Clinic NE- Urgent Care-Riverside New Hope Clinic,P.A. Fairview Clinics Medical Ctr Chiropractic 1695 LorRay Drive 2849 Johnson St NE Riverside at 24th Ave Falk Chiropractic NorthMankato,.LtN 56003 Minneapolis.IN 55418 Minneapolis,MN 5545.1 2738 Winnetka Ave.N. 507-387-8231 612-781-6646 612-672-6771 New Hope,M1I 55427 HealthWorks 612-546-8622 Northfield Monticello 3033 University Ave.SE Chiropractic Minneapolis,MN 55414 Chiropractic New Prague Goehtz Chiropractic 612-379-7244 Monticello Chiropractic Clinic iChiropractic 205 Division Street Northeast Medical Clinic 212 Cedar Street Neck and Back Clinic of New Northfield MN 55057 1229 2nd St.NE Monticello.MN 55362 Prague 507-645-8242 Minneapolis MN 55413 612-295-2262 201 East Main,Box 81 Family Practice 612-379-1119 Family Practice New Prague.MN 56071 River Valley Clinic,P.A. Silver Lake Clinic Hart Medical Clinic 612-758-5135 1400 Jefferson 3900 Stinson Blvd NE 200 Sandberg Road New Richmond Northfield M N 55057 Minneapolis.IV 55421 Monticello,IN 55362 507-645-2000 612-788-1565 612-295-4060 Chiropractic Internal Medicine South Medical Clinic River Place Family Physicians Vrieze Chiropractic 4310 Nicollet Ave.South 150 West 1st St River Valley Clinic,P.A. 1107 Hart Blvd.Suite 210 Minneapolis. 55409 Monticello,M4V 55362 New Richmond WI 54017 1400 Jefferson 612-327-3503 715-?46-7000 Northfield AV 55057 612-295-3200 507-645-2000 internal Medicine , Internal Medicine New York Mills . Airport Medical Clinic Hart Medical Clinic Norwood 7775 26th Avenue South Family Practice 200 Sandberg Road MeritCare Clinic New York Family Practice Minneapolis.MN 55450 Monticello,MIN 55362 Mills Lakeview Clinic,Ltd. 612-726-1771 612-295-4060 209 Tousley 522 Faxon Rd Family Medical Clinic- Moorhead New YorkMGlls MI 56567 Norwood MN 55368 Fairview Clinics 612-487-2888 3809 42nd Ave So Chiropractic 218-385-2555 Minneapolis. I 55406 Larum-Pladson Chiropractic North Branch Oakdale MI 612-721-6261 Moorhead Center Mall Family Practice Chiropractic Family Medical Clinic NE- Moorhead MN 56560 Chisago Health Services Garth Chiropractic Clinic Fairview Clinics 218-236-5151 1041 Geneva Avenue North 2849 Johnson St NE 7th and Oak Family Practice North Branch.MN 55056 Oakdale,MW 55118 Minneapolis.MI 55418 612-781-6646 MeritCare Clinic Moorhead 612-574-8353 612-731-1953 1301 8th Street So. Internal Medicine Onamia Occupational Medicine I Moorhead MN 56560 Chisago Health Services Airport Medical Clinic 701-234-3200 Family Practice 7775 26th Avenue South Internal Medicine North and Oak Mille Lacs Family Clinic M` Minneapolis IN 55450 orth Branch MIN 55056 201 Kathie St. 612-726-1771 MeritCare Clinic Moorhead 612-574-8353 Onamia,M1N 56359 1301 8th Street So. HealthWorks poi th Mankato 612-332-4101 Moorhead MW 56560 3033 University Ave.SE 701-234-3200 Chiropractic Osakis Minneapolis.MN 55414 612-379-7244 Mora Dehen Chiropractic,Ltd. Family Practice , 1706 Lor Ray Drive Occupational Health Group Chiropractic North Osakis Medical Center North Mankato.Mr 56003 825 S.8th Street.Suite 1208 Mora Chiropractic Clinic 507-388-7744 Highway 127.PO Box W Minneapolis.My 55404 Osakis.MI 119 Lake St. Family Practice 612-336-7119 Mora,MN 55051 612-859-3038 Urgent Care 612-679-1133 Osseo Family Practice Family Practice Preferred WorkCare Primary Care Providers 21-Jun-94 6 I _ Osseo Clinic,P.A. Northwellmily Physicians, Interstate Medical Cente Family Practice 226 Central Ave. P.A. 434 West 4th Street Northwest Family Physicians, Osseo.MV 55369 1495 Hwy.101 North Red Wing,MV 55066 p„A, '` - 612-425-2117 Plymouth.MV 55447 612-388-6749 5810 42nd Ave.North 1 612-476-6776 Internal Medicine Robbinsdale,MN 55422 Paynesville Urgent Care 9 Interstate Medical Center 612-537-8405 Family Practice Urgent Care-Plymouth 2835 S.Service Drive Internal Medicine Paynesville Medical Clinic,P.A Convenience Care Red MV Wing, 55066 g Fernandez,Jr., NLD.,Rafael F. 310 Washburn Avenue 3900 I rnewood Lane 612-388-3503 3366 Oakdale Ave.N.il204 Paynesville.MV 56362 Plymouth.MV 55441 Occupational Medicine Robbinsdale,MN 55422 612-243-3779 612-551-0901 Interstate Medical Center 612-588-4657 Perham- Prescott 2835 5.Service Drive Rogers Chiropractic 'Chiropractic I Red Wing,.'vW 55066 61 2-388-3503 ,Internal Medicine Perham Chiropractic Williamson Chiropractic Bass Lake Physicians Rt 3 Box 23 218 Broad St N. Urgent Care i Y U entCare-Interstate 21305 John Millness Dr Perham,AV 56573 Prescott WI 54021 r Ro ers MN 55374 218-346-2330 715-262-3661 Medical Ctr g 2835 S Service Drive 612-428-2206 Family Practice Princeton Red Wing.MN 55066 MeritCare Clinic Perham Rosemount Chiropractic 612-388-3503 665 3rd Street SW Family Practice Perham.14V 56573 Princeton Chiropractic Renter Rosemount Family Physicians 218-346-4040 501 South 4th Street Princeton MN 55371 Family Practice 15120 Chippendale Pierz Deer River Community Rosemount,14N 55068 612-389-4411 Clinic-Remer(Duluth C 612-423-4114 Family Practice 'Family Practice Box 157 Rosemount Medical Clinic Community Medical Center Rum River Medical Remer,MN 56672 14450 S.Roberts Tr. 200 South 1st Avenue Associates-Princeton 218-566-1441 Rosemount MN 55068 Piers.MN 56364 919 Northland Drive 612-423-1168 612-468-2536 Princeton,& 55371 Richfield Pine City 612-389-3344 Chiropractic 1 Roseville Prior Lake Costanzo Chiropractic Family Practice ,Chiropractic 6519 Nicollet Avenue#201 MinnHealth,P.A. Knox Chiropractic Chiropractic Richfield MN 55437 1050 W.LatpenteurAvenue South Hwy.61,Box 4 Behm Chiropractic 612-861-6605 Roseville,MV 55113 Pine City,.'VIN 55063 4646 Colorado Street SE 612-487-1615 612-629-6717 Prior Lake,MW 55372 Richmond Rosedale Medical Center Nilsson Chiropractic 612-447-3516 Family Practice 2393 Fairview Ave.N. 253 Sth Street Ramsey : Richmond Medical Clinic Roseville.MN 55113 Pine City,MV 55063 21 Ivy Avenue SE 612-785-4300 612-629-2740 Family Practice Richmond.'4V 56368 Roseville Family mily &Industrial Ramsey Medical Center Practice 612-597-2122 Clinic,P.A. 5300153rd Ave.NW 231 S North Snelling Mora Medical Center-Pine g Ramsey.MV 55303 River Falls City Roseville,,LIN 55113 220 3rd Ave 612-1Z7--7180 Chiropractic 612-646-7516 Pine City.‘VIN 55063 Red Wing Kinnikinic Chiropractic Occupational Medicine 612-629-7505 Chiropractic 300 N.River St Physicians Neck&Back Clinic River Falls.WI 54022 3050 Centre Pointe Drive,#200 Plymouth Downtown Chiropractic 715-425-2846 Roseville,MV 55113 Family Practice 419 W.3rd 612-639-9150 Camden Physicians,Ltd.- Red Wing, 55066 Robbinsdale Rosedale Medical Center Four Seasons Office 612-388-3212 Chiropractic 2393 Fairview Ave.N. 9750 Rockford Road 'Family Practice Northwestern College of Roseville,MN 55113 Plymouth.MV 55442 Interstate Medical Center Chiropractic 612-785-4300 612-559-3164 2835 S.Service Drive 3605 France Avenue No. Urgent Care Red Wing,MN 55066 RobbinsdaIe,MN 55422 612-388-3503 612-588-4618 Preferred WorkCare Primary Care Providers 21-Jun-94 7 Urgent Care-Roseville Noi st Medical Center- Hynan Chiropract� Tower 1050 West Larpenteur Spo (Duluth Cl 475 University Ave. - -. Roseville.MN 55113 707 Ash Street St.Paul.AV 55103 Family Practice 612-488-7297 Spooner.lVI 54801 612-222-7331 Ely Medical Center-Tower 715-635-2151 Northwestern College of (Duluth Clinic) Sauk Centre Spring Lake Park Chiropractic Main Street Chiropractic 621 So.Cleveland Tower,MN 55790 Sauk Center Chiropractic 'Chiropractic ] St.Paul.A1N 55116 218-753-6161 519 So Main St Spring Lake Park Chiropractic 612-690-1788 Vadnais Heights Sauk Centre.MN 56378 1611 Hwy LONE Family Practice 312-352-6889 Spring Lake Parlc MN 55432 MinnHealth,P.A. Chiropractic 612-784-1540 261 North Ruth Street Jackson Chiropractic Savage St.Cloud St.Paul.AV 55119 3508 N.Rice St. Family Practice j 612-738-9582 Vadnais Heights,MN 55126 Sundance Medical Clinic, Ltd. 'Chiropractic 612-483-4321 4011 West Highway 13 East Side Chiropractic Internal Medicine Savage,AV' 55378 12:VE Wilson 419 St. Paul Medical Clinic,PLC Virginia 612-890-1555 St.Cloud W 56304 310N.Smith Ave 4460 Chiropractic 612-251-3303 St.Pain MN 55102 Luoma Chiropractic Shakopee 612-224-7505 West Side Chiropractic 301 So 4th St IFamily Practice 4142 2nd Street South Occupational Medicine Virginia,,14N 55792 Sundance Medical Clinic,Ltd. St Cloud AV 56301 United Occupational Health 218-741-3402 323 Naumkeag St. 612-255-5188 280 N.Smith Avenue.Suite 144 Family Practice Shakopee,MN 55379 Family Practice St.Paut,AV 55102 East Range Clinics, Ltd. 612-445-6440 .. Midwest Occupational 612-220-8106 910 N.6th Ave. Shoreview Medicine Stewart Virginia.MV 55792 1545 Northway Drive 218-741-0150 Family Practice St.Cloud MN 56303 Family Practice Silver Lake Clinic 612-251-9675 Stewart Medical Clinic Internal Medicine 300 Bowman Street East Range Clinics,Ltd. 4625 Churchill St.4110 St. Cloud Medical Group,P.A. 910 N.6th Ave. Shoreview,IN 55126 1301 W.St.Germain Stewart,MN 55385 612-481-0818 St.Cloud:%4W 56301 612-562-2558 Virginia.MN 55792 218-741-0150 612-251-8181 Stillwater • Soderville Urgent Care !Occupational Medicine Chiropractic Urgent Care-East Range Family Practice Midwest Occupational Clinics Crosstown Medical Clinic Spore Chiropractic Medicine 910 N.6th Ave. 5898 Omaha Avenue North 17615 Chisholm Street 1545 Northway Drive Virginia,NAt 55792 Soderville,MN 55304 St Cloud AV 56303 Stillwater,MN 55082 612-434-9040 612-439-1013 218-741-0150 612-251-9675 Internal Medicine Family Practice Waeonia Crosstown Medical Clinic St.Croix Falls Stillwater Clinic Family Practice 17615 Chisholm Street !Chiropractic 1500 Curve Crest Blvd Stillwater,:LQV 55082 Lakeview Clinic, Ltd. Soderville.MN 55304 Boat Chiropractic 424 H 5 West 612-434-9040 144 N..4dams St 612-439-1233 Waconiq MN 55387 St.Croix Falls.WT 54024 [Internal Medicine 612-442-4461 Solon Springs 715-483-3913 Stillwater Clinic Family Practice 1500 Curve Crest Blvd. Internal Medicine Northwest Medical Center- St.Michael Lakeview 55082 Lakeview Clinic,Ltd. Solon Springs (Del !Family Practice 612-439-1233 424 Huy.5 West Waconiq MN 55387 South Lake Ave St. Michael Medical Center Solon Springs.WI 54873 703 Thielen Drive Superior 612-442-4461 715-378-2121 St AGchae4 API 55376 :Family Practice Wahpeton Spooner 612-497-2979 Duluth Clinic-Superior Family Practice 318 21 t Ave East Family Practice St. Paul - Super^or. 1VI 54880 MeritCare Clinic Wahpeton 1Ch%ro ractiC 332 2nd Avenue No. p 715-398-6921 Wahpeton,ND 58075 701-642-7000 Preferred WorkCare Primary Care Providers 21-Jun-94 8 Waite Park Wood! r * . Chiropractic I [Chiropractic Ellingson Chiropractic Clinic Back and Neck Pain Clinic 49 2nd Avenue North 1502 Woodlane Dr. Waite Park JlTI 56387 Woodbury,LW 55125 612-251-3828 612-735-8653 Minser Chiropractic Clinic Family Practice 110 S.2nd St..4214 River Valley Clinic,P.A. Waite Park.NN 56387 8450 City Centre Drive 612-253-5650 Woodbury,MW 55125 Watertown 611-731-9410 !Internal Medicine !Family Practice River Valley Clinic,P.A. Lakeview Clinic, Ltd. 3350 City Centre Drive 309 Jefferson Ave.SW Woodbury,MN 55125 Watertown,MV 55388 612-731-9010 612-955-1921 Wayzata Wyoming Chiropractic I !Family Practice Wyoming Medical Center Wayzata Chiropractic 5350 266th St 225 Ferndale Ave.So. Wyoming,ASV 55092 Wayzata.MN 5539! 612-462-1515 612-473-4241 [Internal Medicine White Bear Lake Wyoming Medical Center Chiropractic 5350 266th St Jensen Chiropractic Wyoming,MN 55092 1310 Hwy.96,4102 612-462-1515 White Bear Lake,MV 55110 Zimmerman 612-429-5329 [Family Practice Family Practice Rum River Medical MinnHealth,P.A. Associates-Zimmerman 3220 Bellaire Avenue 12980 Fremont Avenue White Bear Lake,MN 55110 Zimmerman,MW 55398 612-777-5235 612-856-4604 MinnHealth,P.A. 4786 Banning Avenue Zumbrota ` White Bear Lake,my 55110 Family Practice 612-426-6402 Interstate Medical Center- Zumbrota Winnebago 525:VDII Street !Family Practice Zumbrota,MN 55992 Winnebago Medical Center- 507-732-7314 Blue Earth Med Ctr 1151st Ave NW Winnebago,MN 56098 .507-893-3144 Winsted Chiropractic Nygren Chiropractic 111 2nd StM Winsted MN 55395 612-485-3700 Preferred WorkCare Primary Care Providers 21-Jun-94 9 Pref*d WorkCare Provider Direct/1 Specialist and Supportive Providers by City EMITIIIIIIII Orthopedics Orthopedics Physical Therapy Mork Clinic Orthopedic Surgeons, Ltd. Anoka Physical Therapy Orthopedics i 1833 2nd Avenue South 600 W 98th Street*150 6800 78th Ave North Orthopaedic Associates of Anoka..14V 55303 Bloomington,MY 55420 Brooklyn Park 4%&'I 55433 Duluth,P.A. 612-421-3680 612-927-4525 612-560-3553 Ripple River Clinic Physical Therapy Physical Therapy Institute for Athletic Medicine Aitkin,MN 56431 Anoka Physical Therapy Institute for Athletic Medicine 8559 Edinbrook Pkwy#106 218-927-2157 403 Jackson St 600 West 98th Street#100 Brooklyn Park MV 55443 Alb Anoka.,1,441 55303 Bloomington MN 55420 612-493-5668 612-427-0862 612-885-6200 Buffalo Orthopedics Little Falls Orthopedics Bemidji Blue Earth ,Dermatology 320 3rd Avenue General Surgery General Surgery Buffalo Clinic,P.A. Albanv.MN 56307 MeritCare Clinic Bemidji Blue Earth Medical Center 1700 Highway 25 N. 612-845-2157 1233 34th Street NW 520 South Galbraith Buffalo,MN 55313 Alexandria Bemidji,MN 56601 Blue Earth.MN 56013 612-682-1313 218-759-5000 507-526-7371 Gastroenterology General Surgery (Ophthalmology Neurology Buffalo Family&Specialty Alexandria Clinic,P.A. MeritCare Clinic Bemidji Blue Earth Medical Center Care Center,P.A. 610 Fillmore SL.PO Box 1149 - 1233 3411,Street NW 520 South Galbraith 303 Catlin Alexandria,IV 56308 Buffalo.MN 55313 Bemidji,MN 56601 Blue Earth.MN 56013 612-763-5123 218-759-5000 507-526-7371 612-682-5225 Mental Health Services Orthopedics Orthopedics General Surgery Uexandria Clinic,P.A. MeritCare Clinic Bemidji Blue Earth Medical Center Buffalo Clinic,P.A. 610 Fillmore St.PO Box 1149 1233 34th Street NW 520 South Galbraith 1700 Highway 25 N. Alexandria MN 56308 Bemidji.MW 56601 Blue Earth,.14V 56013 Buffalo,MN 55313 612-763-5123 218-759-5000 507-526-7371 612-682-1313 Neurology Physical Therapy Buffalo Family&Specialty Brooklyn Center ..,. Care Center,P.A. Alexandria Clinic,P.A. MeritCare Clinic Bemidji 303 Catlin 610 Fillmore R.PO Box 1149 1233 34th Street NW Orthopedics Buffalo,MN 55313 Alexandria..44V 56308 Bemidji,MN 56601 Midwest Spine Institute,P.A. p 612-682-5225 612-763-5123 218-759-5000 3300 County Rd 10.Suite 520 I 1 !Neurology Physical Therapy I Podiatry I Brooklyn Center,MN 55429 Douglas County Hospital MeritCare Clinic Bemidji 612-566-5042 Buffalo Clinic,P.AN. 1700 Highway 25 N. 111 17th Avenue East 1233 34th Street NW Physical Therapy Buffalo,1ellV 55313 Alexandria.ASV 56308 Bemidji,AZ'56601 Midwest Physical Therapy 612-682-1313 , 612-762-6079 218-759-5000 3300 County Road 10 11520 Physical Therapy-FCE/ Radiology Brooklyn Center,MN 55429 Ophthalmology WH Buffalo Family&Specialty Northern Radiology 612-560-6177 Care Center,P.A. Douglas County Hospital Consultants 303 Catlin (Return-To-Work) 4210 Highway 71 North Brooklyn Park Buffalo,UV 55313 111 17thAvemte East Bemidji,MN 56601 Orthopedics Alexandria,,LNV 56308 p 612-682-5225 218-751-6127 t di Park M P Brooklyn arecal Center 612-762-6103 'Orthopedics Bloomington 5805 74th Ave.North Buffalo Clinic,P.A. Anoka `_ Brooklyn Park MN 55443 1700 Highway 25 N. , Ophthalmology 612-572-5700 Buffalo,MN 55313 IGeneral Surgery Eye Physicians&Surgeons, �_ Mork Clinic ,Otolaryngology 61. 682-1313 P'`� Brooklyn Park Medical Center 1833 2nd Avenue South 600 West 98th Street 5805 74th Ave.North Anoka,MN 55303 Bloomington.MN 55420 Brooklyn Park MV 55443 612-421-3680 612-884-8338 612-572-5700 Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 10 i Buffalo Family&Specialty Institute athletic Medicine !Physical Therapy-FC1 Care Center,P.A. 30S East et Blvd#292 IWH Clearbrook 303 Catlin Burnsville,MN 55337 • Rum •River Therapy Center !Physical Therapy Buffalo.MN 55313 612-892-2650 (WH/FCE) MeritCare Clinic Clearbrook 612-682-5225 Physical Therapy:Hand 725 So.Dellwood Elm Street Otolaryngology 1 Therapy Cambridge. t4N 55008 Clearbrook MN 56634 ; Buffalo Clinic,P.A. Fairview Hand Center(Ridges) 612-689-7782 218-776-3124 1700 Highway 25.V. 201 East Nicollet Blvd. Cannon Falls Bufalo.MN 55313 Burnsville•MV 55337 Clearwater 612-682-1313 612-892-2121 �Neurolo Buffalo Family 84 Specialty !Plastic Sure Cannon Falls Community (General Surgery 1 Care Center,P.A. � g Surgery �' 5t. Cloud Medical Group- Edina Plastic Surgery Hospital Clearwater 303 Catlin 303 East Nccollet Blvd.4330 1116Mill St W. 615 Nelson Drive Buffalo..1.1N 55313 Burnsville.,1411 5533 7 Cannon Falls.MV 55009 Clearwater,MV 5 320 612-682-5225 612-435-7711 507-263-4221 612-558-2293 Physical Therapy 1 1Podiatry Excel Physical Therapy Burnsville Foot Clinic Champlin Cloquet 108 Many Drive 12940 Harriet Ave So#210 Ophthalmology Orthopedics Buffalo,MW 55313 Burnsville,MV 55337 Champlin Medical Center Orthopaedic Associates of 612-682-2439 612-890-4061 11269 Jefferson Hwy. Duluth,P.A. Burnsville Champlin.,LW 55316 417 Skylind Blvd Cambridge 612-427-9620 Cloquet.MN 55720 Mental Health Services I Chanhassen Dermatology 218-879-1271 Minneapolis Clinic of Professional Medical Assoc Neurology, Ltd. .. (Cambridge Clinic) Orthopedics Cold Spring 305E.Vicollet Blvd 626 SW 7th Avenue Orthopaedic Consultants,P.A. {General Surgery ` Burnsville.MN 55331 Cambridge,It&i 55008 470 West 78th Street St. Cloud Medical Group- 612435-8516 612-689-1411 Chanhassen,MW 55317 Neurology I !General Cold Spring i �General Surgery 612-934-0570 402 N.Red River Ave#2 Minneapolis Clinic of Professional Medical Assoc Chisago City Cold Spring,MN 56321 Neurology, Ltd. (Cambridge Clinic) g 612-685-8641 305E Nicollet Blvd 626 SW 7th Avenue Dermatology Physical Therapy Burnsville.:Ctrl 55337 Cambridge.UV 55008 Chisago Health Services Great River Physical Therapy 612-435-8516 612 4894411 11685 Lake Blvd North 402 Red River Avenue No. Ophthalmo logy 1 (Ophthalmology Chisago City,MN 55013 Cold Spring,MV 56320 Eye Physicians&Surgeons, Professional Medical Assoc 612-257-8400 612-685-7155 P.A. (Cambridge Clinic) General Surgery 14050 Nicollet dve.So. 6265W;thavetttte Columbia Heights Chisago Health Services Burnsville.MW 55337 Cambridge,MN 55008 611-135-1170 11685 Lake Blvd North Orthopedics 612-689-1411 Chisago City.MN 55013 Columbia Park Clinic Orthopedics i ;Orthopedics ! 612-257-8400 4000 Central Avenue NE Orthopaedic Consultants,P.A. North Suburban Orthopaedics !Neurology Columbia Heights.lviN 55421 r 14050 Nicollet Ave.So.#210 Sc Sports Medicine Burnsville.MN 55337 Chisago Health Services 612-572-5700 626 SW 7th Avenue 612-892-5977 11685 Lake Blvd North Cambridge.MN 55008 ,L1N 55013 Coon Rapids Chisago Ciry Orthopaedic Consultants,P.A. 612-434-6622 612-257-8400 Dermatology 305 East.Vicollet Blvd Professional Medical Assoc Burnsville.,LLV 55337 (Cambridge Clinic) ,Ophthalmology Associated Skin Care Chisago Health Services Specialists,P.A. 612-892-1800 626 SW 7th Avemie g Physical Therapy Cambridge,MN 55008 11685 Lake Blvd North 3960 Coon Rapids Blvd'4116 Fairview Ridges Physical 6124894411 Chisago Ciry,MN 55013 Coo Rapids MN 55433 y ! 612-257-8400 612-571-4000 Therapy Physical Therapy zot East,vicotlerBlvd Orthopedics Coon Rapids Medical Center Rum River Therapy Center- 9055 SpringbrookDr. t - Burnsville,MV 55337 Cambridge Chisago Health Services 612-892-2121 725 So.Dellwood 11685 Lake Blvd North Coon Rapids.MN 55433 Cambridge,MV 55008 Chisago City,MN 55013 612-780-9155 612-689-7782 612-257-8400 General Surgery Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 11 Coon Rapids Medical Center Terk Industrial MeritCare Clinic ilit Lakes Neurosurgery 9055 SpringbrookDr. Retilliptation 1245 S Washington Duluth Clinic -- Coon Rapids..VIN 55433 8960 SpringbrookDrive.Ste 140 Detroit Lakes,MN 56501 400 East 3rd St 612-780-9155 Coon Rapids.MV 55433 218-846-2000 Duluth.Mil 55805 Mental Health Services 1 612-785-7966 118-725-3156 Two Rivers Center,Inc. Duluth Coon Rapids Medical Center CE Ophthalmology 9055 SpringbrookDr. � Cardiology Coon Rapids.,VIN 55433 3505 Northdale Blvd.NW Clinic 612-730-9155 Coon Rapids.MV 55448 Duluth Clinic 400 East 3rd St 612427-0032 400 East 3rd St Duluth.L1N 55805 "Neuro logy 1 Duluth.MN 55805 218-725-3156 Radiology Minneapolis Clinic of 218-725-3156 Orthopedics Neurology, Ltd. Suburban Radiological Dermatology #109 3960 Coon Rapids Blvd. Consultants Duluth Clinic Duluth Clinic 400 East 3rd St Coon Rapids.,W1‘1 55433 W 3960 Coon Rapids Blvd#102 ,_ Coon Rapids.MV 55433 -4 i 400 East 3rd St Duluth. Lf1Y 55805 61: -8320 Duluth,MN 55805 Ophthalmology 612-427-9440 218-725-3156 Z18-" 5-3156 Orthopaedic Associates of Coon Rapids Medical Center Cottage Grove Emergency Medicine Duluth,P.A. 9055 SpringbrookDr, Physical Therapy Duluth Clinic 1000 East First St..Suite 402 Coon Rapids.MN 55433 400 East 3rd St Duluth.MV 55805 612-780-9155 Family Physical Therapy of Cottage Grove Duluth.MV 55805 218-712-5 513 Orthopedics 7500 80th Street S.#101 218-725-3156 Otolaryngology Coon Rapids Medical Center Cottage Grove,MN 55016 Urgent Care-ReadyCare St. Duluth Clinic 9055 Springbrook Dr. 612-459-9686 Luke's Hospital 400 East 3rd St Coon Rapids.MN 55433 915 East 1st St Duluth.MV 55805 612-780-91.55 - Crystal Duluth.MY 55805 218-725-3156 North Suburban Orthopaedics General Surgery 218-726-5555 physiatry &Sports `Medicine Gastroenterology Duluth Clinic 3960 Coon Rapids Blvd.Ste.315 Northwest Family Physicians, P.A. uluth Clinic 400 East 3rd Sr Coon Rapids.MY 55433 400 East 3rd St Duluth.,LILY 55805 61?-=2?-1476 5502 W Broadway Crystal,MV 55428 Duluth OLIN 55805 218-725-3156 Orthopedics:Hand Surgery( 218-725-3156 612-537-8475 ',Physical Therapy Landmark Orthopedics,Ltd. Physical Therapy Northland Gastroenterology St. Luke's Hospital PT 3960 NW Coon Rapids Blvd#104 and Surgery,P.A. Coon Rapids MN 55433 Institute for Athletic Medicine St Luke's Hospital 3 East 915 East First Street 5510 West Broadway#205 Duluth 1ZV 55805 612-641-0673 Duluth.:La155805 L1N 55438 218-726-5373 Crystal. Otolaryngology 611-537-1208 218-725-6050 Physical Therapy-FCE/ Coon Rapids Medical Center General Surgery WH 9055 SpringorookDr. Detroit Lakes. - Duluth Clinic St.Luke's Physical Therapy Coon Rapids.MN 55433 400 East 3rd St (WH/FCE) General Surgery 612-730-9155 Duluth,M1Y 55805 915 East First Street MeritCare Clinic Detroit Lakes 218-7 25-3156 'Physical Therapy Dulurh..L1N 55805 1245 S.Washington Mental Health Services 218-726-5373 Coon Rapids Medical Center Detroit Lakgs.MW 56501 9055 Springbrook Dr. 218-846-2000 Adult OP Mental Health 1Plastic Surgery Coon Ra Rapids, 55433 Services p Mental Health Services Duluth Clinic 612-730-9155 St.Luke's Hospital 400 East 3rd St TeamWu.rk Industrial MeritCare Clinic Detroit Lakes Duluth.MN 55805 Duluth,MN 55805 Rehabilitation 1245 S.Washington 218-726-5555 Detroit Lakes, 56501 2I8-725-3156 8960 SpringirookDrive,Ste 140 Duluth Clinic Podiatry Coon Rapids,MY 55133 218-816-2000 400 East 3rd St 612-785-7966 Orthopedics Duluth,MW 55805 Duluth Clinic Two Rivers Center,Inc. MeritCare Clinic Detroit Lakes 218-725-3156 400 East 3rd Sr Duluth,MN 55805 3505 Norrhdale Blvd NW 1245 S.Washington Neurology 218-725-3156 Coon Rapids.MY 55448 Detroit Lakes,MN 56501 Duluth Clinic 612-4274032 218-846-2000 Radiology 400 East 3rd St Physical Therapy-FCE/ Physical Therapy Duluth SAT 55805 WH 218-725-3156 Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 12 Duluth Radiologists,P.A. Adult Ortal Health Fairview Southdale Phys.) Edina Plastic Surgery 324 Medical Arts Bldg Services Therapy 3625 West 65th Street Duluth.MV 55085 Fairview Southdale Hospital 6401 France Avenue South Edina.MN 55435 218-722-3185 Edina,MN 55435 Edina..t01 55435 612-925-1765 Ea n 612-924-5000 612-924-5060 !Radiology Neurology Industrial Medicine&Hand Cenntennial Lakes MRI- Orthopedies Minneapolis Clinic of Therapy Consulting Rad. Ltd Orthopaedic Consultants,P.A. Neurology, Ltd. 6545 France Ave So 4#401 7373 France Ave So#101 6363 France Ave.S..Suite 200 Edina V 55.135 1440 Duckwood Drive .14 Edina,.LAN 55435 Edina.M2V 55435 612-925-1609 Eagan..6AN 55122 612-831-9300 612-688-7856 612-920-7200 Institute for Athletic Medicine Consulting Radiologists,Ltd. Ophthalmology 7201 Washington Avenue So. Physical Therapy f P gY 6545 Fr V 55435 So#302 Eye Physicians&Surgeons, Edina MV 55439 , Edina.MY S543S Institute for Athletic Medicine P.A. 612-944-5314 612-927-7017 1440 Duckwood Drive Institute for Athletic Medicine Eagan,SLY 55132 4450 West 76th Street Suburban Radiological 612-688-7857 Edina,,VIN 55435 7110 France Avenue South Consultants 612-831-8811 Edina VIN 55435 6545 France Ave So#471 Spectrum Therapy Centers 612-920-8525 990 Lone Oak Road Suite Centers Orthopedics Edina.MN 555435 Orthopaedic Consultants,P.A Saunders Therapy Centers 612-9274689 Eagan.SW 55121 p ' 6550 York..venue South 612-686-0098 7201 Washington Ave.So 4100 Suburban Radiological Edina, 55439 Edina..14V 55435 Consultants Physical Therapy-FCE/ 612-924-0199 7373 France Ave So#204 WH 612-944-2519 . Orthopaedic Consultants,P.A.pectrum Physical Therapy-FCE/ Edina,MN 55345 Spectrum Therapy Center WH 612-893-0588 Spec. m 7373 France Ave.So..Suite 312 Lone Oak Road Suite 118 Edina.MN 55435 Industrial Medicine&Hand 990 Lo Elk River Eagan.990 Lo.eLV 55121 612-832-0076 Therapy 6545 France Ave So#4401 !Orthopedics 612-686-0098 Orthopaedic Consultants,PA P Edina MN 55435 6363 France Ave.So.Suite 500 612-925-1609 North Suburban Orthopaedics Eden Prairie Edina,MY 55435 &Sports Medicine 'Dermatology 612-925-2535 Saunders Therapy Centers ? 501 Main Street Suite 102 gY Orthopedic Surgeons,Ltd ) Elk over. 1- 55330 Associated Skin Care 6550 York Avenue South Specialists,P.A. 6363 France Ave.S.#404 Edina,MV 55435 612-141-0301 8eci Specialists, Cloud Dr.#105 Edina,MN 55435 612-924-0199 Orthopaedic Consultants,P.A. Eden Prairie,MV 55344 612-927-4525 290 Main Street Physical Therapy:Hand Elk River MV 55330 612-5714000 Southdale Orthopedics,P.A. Therapy ■ 6545 France Avenue S.. #404 612-441-0298 'Orthopedics Fairview Hand Center Edina,MN 55435 Physical Therapy Southdale Orthopedic Surgeons,Ltd. 612-920-6322 (Southdale)) Two Rivers Center,Inc 830 Prairie Center Dr.4140 6545 France Ave So.Suite 366 Eden Prairie. me 55314 (Orthopedics:Hand Surgery Edina VIN 55435 530 3rd Street Orthopaedic Consultants,P.A. 612-924-1520 Elk 612-441-8111 41- 55330 612-944-9606 p 612-441-8111 ;Physical Therapy 7373 France Ave.So..Suite 312 Industrial Medicine&Hand Institute for Athletic Medicine Edina MV 55435 Therapy Ellsworth 612-832-0076 6545 France Ave So 4#401 830Pr330 Prairie Center Dr.#170 airie Center 55344 Pain Programs Edina MV 55435 Mental Health Services 612-946-1131 Pain Management Center 612-925-1609 Interstate Medical Center (Southdale) Plastic Surgery 230 Cairns Street Ldina. 6545 France Ave So.Suite 270 Adson&Fasching Plastic Ellsworth,fir?54011 , Edina.MN 55435 Surgery,P.A. 715-273-5061 Electrodiagnostics-EMG 612-924-5542 6545 France Ave.So.#240 Bland,M.D., Charles S. Edina3S Fargo ;Physiatry .MW 554 6545 France Ave.ve S.o.4323 612-920-2600 Cardiolo Edina.LAN SS Spine Care Center(FV- gY Southdale) Associates In Plastic Surgery, MeritCare Medical Group 612-926-1165 6545 France Ave So,Suite 280 P A- 737 Broadway !Mental Health Services Edina,MN 55435 6545 France Ave.S.4586 Fargo.ND 58123 612-924-5048 Edina.MV 55435 701-22 31-2000 Physical Therapy 612-522-1111 Emergency Medicine 21 J Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 13 MeritCare Medical Group Mere Broadway Health Cardiology i Fridley Medical Center 737 Broadway Cen Forest Lake DoctorsL'lfnic 7576 Madison St.NE Fargo.ND 58123 736 Broadway 121 SE 11 th Avenue Fridley.MV 55432 701-234-2000 Fargo.ND 58123 Forest Lake,MCI 55025 612-785..4500 General Surgery ! 701-234-2000 612-464-7100 Fridley Plaza Clinic MeritCare Medical Group !Otolaryngology Dermatology 6341 University Ave.NE 737 Broadway MeritCare Medical Group Forest Lake Doctors Clinic Fridley.MN 55432 Fargo,ND 58123 737 Broadway 121 SE 11th Avenue 612-572-5710 701-234-2000 Fargo,ND 58123 Forest Lake.,!MIN 55025 Neurosurgery MertiCare Broadway Health 701-234-2000 612-464-7100 Minneapolis Neurological Centre Physiatry Surgeons,Ltd. General Surgery 736 Broadway MeritCare Medical Group 8290 University Avenue Fargo,ND 58123 Forest Lake Doctors Clinic F arg 737 Broadway Fridley MN 55432 121 SE 11th Avenue 701-234-2000 Fargo,ND 58123 satellite only Forest Lake.MN 55025 !Mental Health Services ! 701-234-2000 612-164-7100 Ophthalmology 1 Adult OP Mental Health !Physical Therapy Fridley Medical Center Services Ophthalmology MeritCare Hospital Associated Eye Physicians& NE St NE MeritCare Hospital Fridley,MN 55432 720 Fourth Street No. Fargo,ND 58122 Surgeons,Ltd. Fargo,ND 58122 828 So.Lake Street 612-785-4500 701-234-6000 701-234-6000 Forest Lake, 55025 Fridley Plaza Clinic ,Y9 MeritCare Medical Group MeritCare Medical Group 612-464-8000 6341 University Ave.NE 737 Broadway 737 Broadway Fridley,MN 55432 Orthopedics Fargo,ND 581 23 Fargo,ND 58123 612-572-5710 701-234-2000 Forest Lake Doctors Clinic 701-234-2000 Orthopedics 121 SE 11th Avenue Neurology - MertiCare Broadway Health Forest Lake,114 55023 Fridley Medical Center V MeritCare Clinic Neuroscience Centre 7576 Madison St.NE 700 1st Ave.S. 736 Broadw 612-464-7100 Broadway Fridley,.1tV 55432 Fargo,ND 58103 Fargo,ND 38123 Otolaryngology 612-785-4500 701-234-4000 701-234-2000 Forest Lake Doctors Clinic Fridley Plaza Clinic MeritCare Medical Group 'Plastic Surgery ! 121 SE 11th Avenue 6341 University Ave.NE 737Broadway MeritCare Medical Group Forest Lake. 55025 Fridley.MN 55432 Fargo,ND 58123 737 Broadway 612-464-7100 612-572-5710 701-234-2000 Fargo,ND 58123 !Physical Therapy Northwestern Orthopaedic !Neurosurgery 701-234-2000 Orthopaedic Sports,Inc. Surgeons MeritCare Medical Group !Podiatry 146 North Lake Street 8290 University Ave.NE#200 737 Broadway MeritCare Medical Group Forest Lake.ASV 55025 Fridley MN 55432 Fargo.ND 58123 737 Broadway 612-646-8502 612-786-9543 701-234-2000 Fargo.ND 58123 'FM�ex . Otolaryngology !Ophthalmology 701-234-2000 Fridley Plaza Clinic Dermatology 6341 University Ave.NE MeritCare Medical Group t3' 737 Broadway Faribault Associated Skin Care Fridley.11N 55432 Fargo.ND 38123 !Orthopedics Specialists,P.A. 612-572-5710 701-234-2000 500 Osborne Road NE#330 physical Therapy Orthopedic and Fracture 55432 Fridley, !Oral/Dental Surgery Clinic MN Northern PT&Athletic MeritCare Medical Group 633 SE 1st Street 612-571-1000 Medicine 737 Broadway Faribaul;MY 55021 Associated Skin Care 8290 University Ave.NE#200 Specialists,RA. Fridley,MN 55432 Fargo.Ni) 58123 507-334-1601 7205 Universiry,tveNE 612-786-2340 701-234-2000 Farmington Fridley,MN 55432 Orthopedics Physical Therapy-FCE/ p 612-571-4000 WH MeritCare Medical Group General Surgery Emergency Medicine Industrial Medicine&Hand 737 Broadway River Valley Clinic,P.A. Fridley Medical Center Therapy Fargo.ND 58123 910 Main Street 7576Madison St.NE 8290 University Ave#100 701-234-2000 Farmington,MN 55024 Fridley,MN 55432 Y Fridley,MN 55432 612-463-7181 612-785-4500 612-784-0436 Forest Lake General Surgery Physical Therapy:Hand Therapy Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 14 i Industrial Medicine&Hand MinneapilliClinic of Family Physical Therap Hudson Physicians,Ltd. Therapy Neuroloin Program Hastings 400 Wisconsin Street - 8290 UniversiryAve 4 100 4225 Golden Valley Road 1285 NiningerRoad Suite 107 Hudson,WI 54016 + Fridley,4%'W 55432 Golden Valley,MY 55422 Hastings..NN 55033 71 5-386-8880 612-784-0436 612-588-0661 612-438-3920 Radiology I Physical Therapy-FCE/ , HUgo Hastings Suburban Radiological WH Cardio logy Consultants 'Dermatology 1 Family Physical Therapy of Hugo Medical Clinic 500 Osborne Rd 4 240 River Valley Clinic,P.A. Hastings 1 145 North Forest Blvd. Fridley,MW 55432 1210 W.First St 1285 Nininger Road Suite 107 Hugo.NV 55038 612-786-9460 Hastings.MN 55033 Hastings,MN 55033 612-426-9216 612-438-1800 612-438-3920 Glencoe Dermatology Gastroenterology 'Podiatry { Hugo Medical Clinic Dermatology River Valley Clinic,P.A. River Valley Clinic,P.A. 14145 North Forest Blvd. Glencoe Medical Clinic,P.A. 12101V.First St. 1210 W First St. 52518th Street East Hastings,MW 55033 Hugo.AN 55038 Hastings MN 55033 g 612-426-9216 Glencoe,MN 55336 612-138-1800 612-438-1800 Neurology 612464-3116 General Surgery I Hibbing - � Hugo Medical Clinic ,General Surgery , River Valley Clinic,P.A. I 4145 North Forest Blvd. Glencoe Medical Clinic,P.A. 12101 First St. Physical Therapy Hugo,AV 55038 52518th Street East Hastings.114V 55033 Mesabi Regional Medical 611-426--9216 Glencoe.MN 55336 612-438-1800 Center Otolaryngology 612-864-3116 Mental Health Services 750E 34th St• Hibbing,MN 55746 Hugo Medical Clinic Orthopedics River Valley Clinic,P.A. 218-262-4881 14145 North Forest Blvd Orthopaedic Consultants,PA 1210 W.First St. Hugo.MN 55038 701 East 18th St Hastings,MN 55033 Hinckley 612-426-9216 Glencoe.i 4l 55336 612-438-1800 612464-3121 Ophthalmology General Surgery Hutchinson !Podiatry River Valley Clinic,P.A. Mora Medical Center- Dermatology 9Y Nichols,DPM,William N. 1210 W.First SL 302 Fire Monument Hutchinson Medical Center, 705 East 18th St Hastings.IAN 55033 Hinckley,MN 55037 P.A. Glencoe,AWV 55336 612-438-1800 612-384-6189 3 Century Avenue 612464-3121 Orthopedics Hutchinson.MN 55350 Golden Valley . '�- Landmark Orthopedics,Ltd. Hudson 612-537-2020 1285 NiningerRoad Suite 203 Emergency Medicine General Surgery Mental Health Services { Hastings.MN 55003 Hudson Physicians,Ltd. Hutchinson Medical Center, Minneapolis Clinic of 612-641-0673 P.A. 400 Wisconsin Street Neurology, Ltd. River Valley Clinic,P.A. 3 Century Avenue Hudson, WI 54016 4225 Golden Valley Road 1210 W.First St. 715-386-8880 Hutchinson.MN 55350 Gorden Valley,MN 55422 Hastings.MN 55033 612-587-2020 512-588-0661 �_ General Surgery 61 138-1800 Neuro logy Neurology !Orthopedics:Hand Surgery] Hudson Physicians,Ltd. Hutchinson Medical Center, Minneapolis Clinic of Landmark Orthopedics,Ltd. 400 Wisconsin Street P.A. Neurology,Ltd. Hudson,WI 54016 1285 NiningerRoad Suite 203 715-386-8880 3 Century Avemte 4225 Golden Valley Road Hastings,MN 55003 Hutchinson.Aril 55350 Golden Valley.,L11V 55422 612-6414673 Neurology 612-587-2020 612-588-0661 River Valley Clinic,P.A. Hudson Physicians,Ltd. Oral/Dental Surgery Ophthalmology 1210 W.First St. 400 Wisconsin Street Wang,DDS,P.A.,Joseph H. Medical Vision Center Hastings.NW 55033 Hudson,WI 54016 45 East Library Square 5657 Duluth Street 612-438-1800 71 5-386-8880 Hutchinson MV 55350 Golden Valley,,14V 55422 Otolaryngology Orthopedics 612-587-4644 612-542-1176 River Valley Clinic,P.A. Hudson Physicians,Ltd. Otolaryngo logy 1 Pain Programs j 400 Wisconsin Street 1210 Wt.First SL 55033 Hastings.,t IN Hudson,WI 54016 612-438-1800 715-386-8880 Physical Therapy Otolaryngology Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 15 Hutchinson Medical Center, M ato OFC Back Care Ce Neurological Associates of St. P.A. 309 Holly Lane Paul.P.A. - -- 3 Century Avenue Cardiology Mankato.MN 56001 1655 Beam Avenue Hutchinson.n MN 55 350 Mankato Clinic 507-345-6299 Maplewood.MN 55119 612-587-2020 1230 East Main Si Physical Therapy Sports 612-221-9051 Medicine Center O Jordan Mankato,MN 56002 Orthopedics 507-625-1811 309 Holly Lane Summit Orthopedic General Surgery ! Mankato,MN 56001 Associates,P.A. !Dermatology Sundance Medical Clinic,Ltd. 507-387-3444 1560 Beam Avenue,Suite D Mankato Clinic Wenger Physical 506 W.2nd St. 1230 East Main St g y Therapy Maplewood,.4N 55109 Jordan.NV 55352 310 Belle Avenue 612-770-5773 tvlankato,MN 56002 Mankato,MN 56001 612-492-3100 507-625-1811 Orthopedics:Hand Surgery1 507-625-8010 Landmark Orthopedics,Ltd. Lakeville I Gastroenterology 'Physical Therapy-FCE/ Ij 1655 Beam Ave..Suite 130 Mankato Clinic WH :Orthopedics 1230 East.�fain St Maplewood.MN 55109 OFC Back Care Center Orthopaedic Consultants,P.A. Afanicato AV 56002 612-641-0673 17599 Kemvood Trail 507-625-1811 309H(WH/FCE) Physical Therapy Lakeville.AV 55044 General Surgery Mankato.MN 56001 Family Physical Therapy 612-892-5801 Associates Mankato Clinic 507-345-6299 Litchfield 1230 East Main St 1812 North St.Paul Road Plastic Surgery Maplewood.NN 55109 Mankato,MN 56002 Mankato Clinic 612-779-8550 General Surgery 507-625-1811 1230 East Main St Orthopaedic Sports,Inc Prashad, MD,Darnush !Neurology Mankato.ASV 56002 611 Sibley Ave 1655 Beam Ave..Suite 308 Litchfield AV 55355 Mankato Clinic 507-6254811 Maplewood.A-N 55109 1230 East Main St Podiatry 612-779-6543 612-693-2804 Mankato,M11 56002 Mankato Clinic Neurology 507-625-1811 Milaca 1230 East Main St • Litchfield Medical Clinic Neurosurgery Mankato,ASV 56002 Neurology 611 S.Sibley Ave Mankato Clinic 507-6254811 Rum River Medical Litchfield ASV 55355 1230 East Alain St 612-693-2804 Maple Grove Associates-Milaca Mankato,MN 56002 150 10th Street NW,Suite B Little Falls 507-625-1811 Gastroenterology Milaca MN 56353 Ophthalmology Camden Physicians,Ltd.- 612-983 4101 General Surgery - Mankato Clinic Grove Square Office Orthopedics Little Falls Surgical Clinic 1230 East Main St 13800 83rd Way Orthopaedic Consultants,P.A. 808 Southeast 3rd Street Mankato,AN 56002 Maple Grove,MN 55369 Little Falls ASV 56345 15010th Avenue NW 507425-1811 612--120-5822 Milaca AV 56353 612-632-3611 'Orthopedics General Surgery Neurology p g ry 612-983-6101 Orthopedic and Fracture Camden Physicians,Ltd.- Family Medical Center,P.A. Clinic Grove Square Office Minneapolis 811 SE 2nd Street 309 Holly Lane,Box 3487 13800 83rd Way Emergency Medicine Little Falls,MN 56345 Mankato,ANN 56002 Maple Grove,AV 55369 Airport Medical Clinic 612-632-6611 507-388-6265 612-420-5822 7775 26th Avenue South Orthopedics 'Otolaryngology Maplewood Minneapolis,MN 55450 Little Falls Orthopedics,P.A. Mankato Clinic 612-726-1771 808 3rd Street SE 1230 East Main St Cardiology General Surgery Little Falls MN 56345 Mankato,AvN 56002 St.Paul Heart Clinic Camden Physicians,Ltd.- 612-632-3671 507-625-1811 1675 Beam Ave#101 Camden Office Long Prairie Physical Therapy Maplewood MN 55109 1206 No.42nd Avenue - Immanuel St.Joseph's 61- 7i9-9449 Minneapolis,AV 55412 Orthopedics . Physical Therapy Mental Health Services 612-522-6601 Little Falls Orthopedics,P.A. 1025 Marsh St.,PO Box 8673 MinnHealth,P.A. Family Medical Clinic- Long Prairie Clinic Mankato,MN 56002 2716 Upper Afton Road Fairview Clinics Long Prairie.54W 56347 507-345-2669 Maplewood MN 55119 3809 42nd Ave So 612-732-2131 612-739-4599 Minneap0li3,544W 55406 Neurology 612-721-6261 Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 16 P Mental Health Services Landmarhopedics,Ltd. Consulting Radiologists,III 7775 26th So..Suite 130 2425 Chicago Ave So#306 Moose Lake Adult OP Mental Health ag ' Services Minneapolis,MN 55450 Minneapolis.MN 55404 Orthopedics Fairview Riverside Medical Center 612-641-0673 612-371-1951 Orthopaedic Associates of Minneapolis.MN 55455 Orthopaedic Consultants,P.A. Consulting Radiologists, Ltd. Duluth,P.A. 612-672-6000 701 25th Ave.So..Suite 402 825 So 8th St#220 Gateway Clink s Silver Lake Clinic Minneapolis.MN 55454 Minneapolis.MN 55404 Moose Lake.MV 55767 3900 Stinson Blvd NE 612-339-8976 612-333-4634 218-389-6150 Minneapolis.ieapolis.MW 55421 !Pain Programs i Consulting Radiologists,Ltd. 612..788-1565 Pain Rehabilitation Ctr. 920E 28th St 4240 Mora Neurology (Riverside) Minneapolis MN 55407 General Surgery Midwestern Neurological& 2450 Riverside Avenue 612-363-3850 Mora Medical Center Psychiatric Consultants Minneapolis,MV 55454 Consulting Radiologists,Ltd. 224 Seventh St. 825 Nicollet Mall 4650 612-672-283 5 710E 24th St 4 204 Mora.Ml 55051 Minneapolis.AN 55402 ':Physical Therapy ' Minneapolis MV 55404 612-679-1313 612-332-1356 Institute for Athletic Medicine 612-336-5380 Neuro logy Minneapolis Clinic of 701 25th Ave So 4500 Minnetonka Mora Medical Center Neurology,Ltd. Minneapolis.MN 55454 2545 Chicago Ave.S.#102 612-672-6697 Physical Therapy 224 Seventh St. Minneapolis.MV 55407 Mora,MV 55051 Minnesota Lumbar Spine Institute for Athletic Medicine 612-679-1313 612-363-4070 Clinic 2000 Plymouth Road#365 Physical Therapy Ophthalmology 825 S.8th Street,Suite 510 Minnetonka MN 55305 Medical Vision Center Minneapolis,MN 55404 612-525-1883 Kanabec Hospital 4001 Stinson Blvd NE 4224 612-338-0566 300 Clark St Minneapolis.MN 55421 Minnesota Lumbar Spine Monticello Mora MN 55051 612-781-6911 Clinic 612-679-1212 Dermatology Orthopedics 60624th.IvemteSo..Suite 708 Hart Medical Clinic North Mankato Minneapolis,SLY 55454 Metropolitan Spine Group 200 Sandberg Road 606 24th Ave So 4 701 611-341-9218 Physical Therapy Monticello.MN 55362 Riverside Spine&Orthopedic Wenger Physical Therapy Minneapolis.-UV 55454 612-295-4060 612-341-9220 i Genera/Surgery 1681 Commerce Drive 606 24th Ave So,Suite 301 g North Mankato,11N 56003 Minneapolis Sports Medicine Minneapolis.MV 55454 Hart Medical Clinic 507_625-8017 Center 200 Sandbe Road 612-672-4940 rg 701 25th Ave.So..Suite 400 Physical Therapy-FCI:/ 'Physical Therapy FCE/ j Monticello.MMt l 55362 WH Minneapolis.MV 55454 y py" ,WH , 612-295-4060 611-339-7734 Wenger Physical Therapy Orthopaedic Consultants,P.A. Minnesota Lumbar Spine Neurology (WH/FCE) 825 So.3th Street Suite 504 Clinic(WH/FCE) River Place Family Physicians 1681 Commerce Drive Lfianeapolis_VW 55404 825 S.8th Street,Suite 510 1107 Hart Blvd.Suite 210 North Mankato.IN l 56003 Minneapolis MV 55404 Monticello,.1/QV 55362 507-625-8017 612-337-0415 Orthopaedic Consultants,P.A. 612-338-0566 612-295-3200 Northfield 606 24th.dve.So..Suite 119 Minnesota Lumbar Spine ;Orthopedics Clinic(WH/FCE) Hart Medical Clinic Dermatology Minneapolis.MV 55454 gy 612-339-1376 606 24th Avenue So..Suite 708 200 Sandberg Road River Valley Clinic,P.A. Minneapolis,MV 55454 Monticello.MPl 55362 Orthopaedic Consultants,P.A. 612-341-9218 1400 Jefferson 612-295-4060 North 606 24th Ave.So.,Suite 300 field MN 55057 Minneapolis.MV 55454 Riverside Work-Up Program North Suburban Orthopaedics 507-645-2000 2450 Riverside Avenue &Sorts Medicine 612-672-6131 Mknneapolis MV 55454 Sports Gastroenterology Orthopaedic Consultants,P.A. 1013 Hart Blvd River Valley Clinic,P.A. 612-672-6705 Monticello. 1 55362 y 701 25th Ave.So.,Suite 402 MLi 1400 Jefferson Nnnea Otis,Mnv 55454 Physical Therapy:Hand 612-441-0301 p Therapy Northfield MIN 55057 612-339-8976 Otolaryngology 507-645-2000 Fairview Hand Center Hart Medical Clinic Orthopaedic Consultants,P.A. 1 (Riverside) General Surgery 74 So.9th Street Suite 711 200 Sandberg Road 606 24th Ave So.,Suite 301 River Valley Clinic,P.A. Minneapolis,MiV 55402 Monticello,M W 55362 Minneapolis,SW 55454 1400 Jefferson 612-332-6757 612-295-4060 612-371-6996 Northfield.MV 55057 Orthopedics:Hand Surgery( !Radiology 507-645-2000 Preferred WorkCare Specialist and Supportive Providers 21-.Jun-94 17 - P.- Ophthalmology Palle Area Health Care Institute for Athleteedicine Interstate Medical Center Linde, MD,Ronald Sys 9750 Rockford Road 2835 S.Service Drive 500 South Water St 200 First St. Plymouth.MN 55442 Red Wing,MN 55066 Northfield..LQV 55057 Payne:ville.MN 56362 612-557-9000 612-388-3503 507-645-6619 612-243-3767 Institute for Athletic Medicine Orthopedics River Valley Clinic,P.A. Perham 1495 Highway 101 North Interstate Medical Center 1400 Jefferson Plymouth,LA'55447 2835 S.Service Drive Northfteld..LbV 55057 General Surgery I 612-476-6782 Red Wing,.14V 55066 507-645 4000 MeritCare Clinic Perham 612-388-3503 Princeton Orthopedics 665 3rd Street SW . Physical Therapy Orthopedic and Fracture Perham MW 56573 Neurology River City Rehab Clinic 218-346-4040 Rum River Medical 133 Kedin Avenue 1381 Jefferson Road Orthopedics Associates-Princeton Red Wing,MV 55066 ,Vorthfteld.14V 55057 MeritCare Clinic Perham 919 Northland Drive 612-388-5011 507-645-7352 66S 3rd Street SW Princeton.MN 55371 Physical Therapy-FCE/ River Valley Clinic,P.A. Perham.ASV 56573 612-389-3344 1Nl.,l 1400 Jefferson 218-346-4040 Ophthalmology River City Rehab(WH/FCE) Northfield MN 55057 :Podiatry Rum River Medical 133 Hedin Avenue 507-615-2000 MeritCare Clinic Perham Associates-Princeton Red Wing,MW 55066 Otolaryngology 665 3rd Street SW 919 Northland Drive 612-388-5011 River Valley Clinic,P.A. Perham,AV 56573 Princeton,MV 55371 1400 Jefferson 218-346-4040 612-389-3344 Robbinsdale Northfield MN 55057 Orthopedics General Surgery 507-645-2000 Pine City Northwestern Orthopaedic Surgeons P.A. Metropolitan Surgical Osseo :' . ,•Y • General Surgery Associates,P.A. Mora Medical Center-Pine 400 Second Street So.,Suite 120 3366 Oakdale Ave.No.#506 General Surgery City Princeton 1LIN 55371 Robbinsdale.MW 55422 Osseo Clinic,P.A. 220 3rd Ave 612-389-9281 612-588-5422 226 Central Ave. PineCity,.L�t 55063 Orthopaedic Consultants,P.A. Mental Health Services Osseo,MN 55369 612-629-7505 9l9 Northland Drive .La NorthWorks Rehab 612425-2117 Princeton,MN 55371 Plymouth 4080 West Broadway Y 612-389-6675 Physical Therapy Rum River Medical Robbinsdale,MW 55422 Institute for Athletic Medicine Gastroenterology Associates-Princeton 612-520-5690 100 Central Avenue North Cam den Physicians,Ltd.- 919 Northland Drive Ophthalmology Osseo,MV 55369 Four Seasons Office Princeton.MI 55371 Northwest Eye Clinic,P.A. 612-424-0534 9750 Rockford Road 612-389-3344 - 3366 Oakdale Ave.No.#402 Plymouth.AIN 55442 Robbinsdale.M N 55422 'Owatonna • Otolaryngology - ... - 612-559-3164 612-588-0755 ! Genera/Surgery Rum River Medical Orthopedics ! Associates-Princeton Orthopedics Orthopedic and Fracture Camden Physicians,Ltd.- 919 Northland Drive Northwest Bone&Joint Clinic Four Seasons Office Princeton,MN 55371 Associates,P.A. 134 Southview,Suite 201 9750 Rockford Road 612-389-3344 3366 Oakdale Avenue North#203 Owatonna,:LLV 55060 Plymouth,OLIN 55442 Robbinsdale,MN 55422 507-451-8866 612-559-3164 Red Wing 612-520-7870 ;Physical Therapy Neurosurgery General Surgery Northwest Bone&Joint Owatonna Physical Therapy Minneapolis Neurological Associates,P.A. g Su eons,Ltd. Interstate Medical Center 3366 Oakdale Avenue North#103 1414 So Oak 2835 S Service Drive Owatonna MV 55060 505 North Hwy 169,Suite 230 Robbinsdale,MN 55422 Plymouth,MN 55441 Red Wing MN 55066 612-520-7870 507-451-8254 612-388-3503 612-544-7562 Pain Programs ' !Mental Health Services Paynesville Orthopedics North Pain Institute 'Neurology rthopaedic Consultants,P.A. Interstate Medical Center 4080 West Broadway.Suite 310 gy 12805 Highway 55,Suite 111 2835 S.Service Drive Robbinsdale.1i4 N 55422 55066 Plymouth,MN 55441 Red Wing.NW 612-520-7246 612-476-0042 612-388-3503 Physical Therapy 'Ophthalmology Physical Therapy Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 18 l Institute for Athletic Medicine Physician k&Back Clinic Crosstown Medical Clinic410 !Neurology 4080 West Broadway 4300 3050 Centr@Tbinte Drive.#200 17615 Chisholm Street St. Cloud Hospital Robbinsdale,MN 55422 Roseville,MN 55113 Soderville.MN 55304 1406 6th Ave.N. 612-533-0541 612-639 4150 612-434-9040 St.Cloud MN 56 303 !Physical Therapy-FCE/ Savage Physical Therapy 612-251-2700 WH Rum River Therapy Center- Ophthalmology ! Industrial Medicine&Hand Orthopedics Crosstown Eye Surgeons &Physicians, Therapy Orthopaedic Consultants,P.A. 17615 Chisholm Street P.A. 3366 Oakdale Ave No 4141 4011 West Highway 13 Soderville, 55304 8 ay 109 Doctors Park Robbinsdale,MN 55422 Savage,MY 55378 6124344040 Si.Cloud.lvW 56303 612-521-3256 612-890-8736 612-253-3637 NorthWorks Rehab(WHIFCE) South St. Paul !Physical Therapy ! Northway Eye Associates 4080 West Broadway Neurology Institute for Athletic Medicine gy 1545 Northway Drive Robbinsdale..1.W 55422 4011 W.Highway 13 Neurological Associates of St. St.Cloud,,vW 56303 612-520-5690 Savage. 55373 Paul,P.A. 612-253-2441 Physical Therapy:Hand 612-882-0758 71019th Avenue North Orthopedics Therapy South St.Paul.MN 55075 St. Cloud Orthopedic Assn., Industrial Medicine and Hand Shakopee 612-221-9051 Ltd. Therapy 3 366 Oakdale Ave No 4141 General Surgery Spooner 1555 Northway Drive Robbinsdale.MN 55422 Sundance Medical Clinic,Ltd. St.Cloud,tIV 56303 323 St !General Surgery 612-259-4100 612-521-3256 s Shakopee,MI 55379 Northwest Medical Center- l Physiatry Plastic Surgery Spooner(Duluth Cl • Adson&Fasching Plastic 612-445-6440 St. Cloud Medical Group,P.A. Surgery,P.A. Ophthalmology 707 Ash Street 1301 W St.Germain Spooner, WI 54801 St.Cloud MN 56301 3366 Oakdale Ave.No.4519 Eye Physicians&Surgeons, 7I5-635-2151 Robbinsdale,,W155422 P.A. 612-251-8181 612-520-7880 1226 East 4th Ave. Spring Lake Park Physical Therapy Associates In Plastic Surgery, Shakopee,MN 55379 Great River Physical Therapy P.A. 612-445-5760 Physical Therapy 1225 West St.Germain St. 3366 0akdale Ave.N.#408 MultiCenter Therapy SL Cloud,MW 56301 Shoreview Highway 612-251-2730 Robbinsdale.MN 55422 i ay 6 g aNE 612-522-1111 Orthopedics Spring LakaParkd4N 55432 Northern Star Therapy,Ltd Rosevile Northwestern Orthopaedic 612-784-3155 1411 West St Germain Surgeons Physical Therapy-FCE/ St.Cloud.MN 56301 !Orthopedics 4625 Churchill Street Suite 200 MultiCenter Therapy St Cloud Orthopedic Assoc Physicians Neck&Back Clinic p 3050 Centre Pointe Drina,4200 612-481-1071 (WHIFCE) Physical Therapy 7700 Highway 65 NE 1555 Northway Drive Roseville,MN 55113 Physical Therapy Spring Lake Park 55432 612-639-9150 Northern PT&Athletic p g St.Cloud,9- 56303 Rosedale Medical Center Medicine 612-784-3155 612-259-4100 2393 Fairview Ave.N. 4625 Churchill Street Suite 200 St.Cloud ,,- Radio logy Roseville.SLY 55113 Shoreview,MY 55126 Center for Diagnostic Imaging 612-785-4300 612-481-1071 !General Surgery 148 Second St So Physical Therapy St. Cloud Medical Group,P.A. St.Cloud MN 56387 Soderville 1301 W.St.Germain 612-251-0609 Family Physical Therapy of St. .144I Cloud, � 56301 St. Radiology,P.A. RoseviIle !Dermatology 1935C1935 Ctv.Rd B2,Suite 140 Crosstown Medical Clinic 612-351-8181 1406 6th Avenue No. le,.L1N 55113 St. Cloud Surgical Associates, St Cloud, V 56303 1761 S Chisholm Street Ltd. 612-255-5619 612-636-2666 Soderville,MN 55304 830 West St.Germain,Suite 200 MultiCenter Therapy 612-434-9040 St.Cloud MN 56301 St-Louis Park 2393 North Fairview Ave General Surgery 612-251-1860 Roseville,MN 55113 Crosstown Medical Clinic Neurology Mental Health Services 612-636-8650 17615 Chisholm Street Minneapolis Clinic of Processus(Mental Health) Neurology,Ltd. Soderville.1&1 55304 600 25th Ave.S.,4211 6490 Excelsior Blvd W-414 1 612-434-9040 St.Cloud.MW 56301 St Louis Park MN 55426 Orthopedics 612-252-2976 612-922-3317 Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 19 • -I Ophthalmology r0 �les Spectrum Therapy r Stillwater Clinic Northwest Eye Clinic,P.A. LantimSrk Orthopedics,Ltd. 360 Sherman Street.S 00 1500 Curve Crest Blvd 6490 Excelsior Blvd Suite W301 1690 University Avenue#180 St.Paul..LN 55102 Stillwater,.L1N 55082 St.Louis Park.LEI 55426 St.Paul,,VIN 55104 612-.291-0266 612-439-1233 612-926-2218 612-645-8980 United Hospital Physical Ophthalmology Radio logy I Landmark Orthopedics,Ltd. Therapy Associated Eye Physicians& Center for Diagnostic Imaging 17 West Exchange St#307 333 North Smirh.4vemte Surgeons,Ltd. 5775 Wav:ata BLvd#190 St.Paul.MN 55101 SC Pain 22 55102 232 llwazeM1ain Street St.Louis Park. 55416 612-227-0200 612-220-8290 Stillwater,MN 55082 612-542-8553 Orthopaedic Consultants,P.A. Physical Therapy-FCE/ 612-439-8500 1690 University Ave.,Suite 410 WH Orthopedics St. Paul_ St.Paul,MN 55104 Saunders Therapy Centers Midwest Spine Institute,P.A. 612-232-4770 (WIi/FCE) Cardiology 1940 So.Greeley St#105 2334 U Summit Orthopedic University 170 dv W.Suite Stillwater,NNW 55082 Affiliated Cardiovascular St.Paul.ALN 55114 Consultants,P.A. Associates,P.A. 612-430-3800 360 Sherman St#250 293 West Seventh S;Suite 100 612-645-8083 P St. Croix Orthopedics,P.A. Sc Paul.�LW St#25 Si.Paul.IN 55102 Spectrum Therapy Center (FCE/WH) 1701 Curve Crest Blvd 612-292-9914 612-297-6909 Stillwater,39-MN 55082 Orthopedics:Hand Surger}i 360 Sherman 55102 Suite 300 612--439-8807 St.Paul Heart Clinic St.Paul.MN 55102 255 No.Smith Heart Avenue#100 Landmark Orthopedics,Ltd. 612-291-0266 Midwest St.Paul..11Y 55102 393 N.Dunlap,Suite 850 Midwest Spine Institute,P.A. St.Paul.MN 55104 'Physical Therapy:Hand 612-292-0616 Therapy 1940 So.Greeley St.#105 Mental Health Services 612-641-0673 Stillwater,MN 55082 Metropolitan Hand Surgery Minnesota Hand Rehabilitation United Hospital P ry 393 N.Dunlap St.,Suite 310 612-130-3800 Assoc. 333 North Smith Ave. St Paul..LN 55104 Physical Therapy 310 N.Smith Ave..Suite 370 St.Paul..LN 55102 612-646-4263 Midwest Physical Therapy 612-220-8000 St.Paul.MN 55102 1940 So.Greeley St.#120 612-291-8773 Radiology y United Pain Center Stillwater,.55082 Otolaryngology Center for Diagnostic Imaging 360 Sherman St.(Fort RoadMed) 612--130-9319 Head&Neck Physicians& 910 Sibley�bfemorialHwy St.Paul.MN 55102 SL Paul,MN 55118 Orthopaedic Sports,Inc. Surgery Clinic 612-220-7246 1700 Tower Drive West 310 N.Smith#120 Neurology 612-455-5500 logy 31 St.Paul,MN 55102 Midwest MRI Stillwater,Mil 55082 Krasnow,M.D.,Brian M. 612-227--0821 250 Thompson St 612- 39-8.:40 280 N.Smith Ave.#415 St.Paul,MN 55102 Physical 4 Therapy-FCE/ [Pain Programs St.Paul.�1 N 55102 612-297-6493 WH United Pain Center 612-224-5848 St.Paul Radiology Midwest Physical Therapy Neurologic Consultants 360 Sherman St.(Fort Road Med) 350 St Peter St#950 1940 So.Greele y St#120 St.Paul..55102 1690 Univervex sity Ave#440 St.Paul.MY 55102 Stillwater,.1.4V 55082 St.Paul. 55104 61 Z-220 2 46 612-228-9160 612-430-9319 :Ph slat ry 612-646-4301 Orthopaedic Sports,Inc(The Neuroi:gicai Associates of St. United Hospital Physical Stt Peter Work Center) Paul,P.A. Therapy 1410 Frontage 55082 Podiatry 280 N.Smith Avenue#550 333 North Smith Avenue Stillwater,MN 55082 St. N.Smith 55102 St.Paul aLW 55102 Nichols,DPM,William N. 612-439-9509 612-220-8290 618 West Broadway 612-221-9051 1 St Peter,MN 56082 Superior ;Neurosurgery ;Physical Therapy Neurosurgery Associates,Ltd. Family Physical Therapy& 507-931-3328 Orthopedics 280 N.Smith#234 Sports Rehab Stillwater Orthopaedic Associates of 28 St.Paul Aar 55102 411 North Lexington Pkwy. Duluth,P.A. 612-2:7-7088 Sc Paul.:LEI 55104 Mental Health Services N.28th&Bill Avenue Ophthalmology I 612-644-8422 Midwest Spine Institute,P.A. Superior, 54880 Saunders Therapy Centers 1940 So.Greeley St.#105 715-392-8370 -8370 Associated Eye Physicians& , Stillwater,30- S5o82 i Surgeons, Ltd. 334 UniversiryAv it Suite 170 1Physical Therapy St Paul 1•N 55114 6olog 0-3800 280 No.Smith Ave.Suite 840 612-645-8083 Neurology St.Paul IN 55102 612-222-5666 Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 20 Center For Muscle&Joint Physic rapt'-FCE/ I MeritCare Clinic Wahp. MinnHealth,P.A. _ Therapy 1WH 1 332 2nd Avenue No. 4786 Banning Avenue 1420 Oakes Avenue Iron Range Rehabilitation Wahpeton.ND 58075 White Bear Lake.MN 55110 Superior,WI 54880 Center 701-642-7000 612-426-6402 715-394-6355 1001 N.9th Ave General Surgery I MinnHealth,P.A. Virginia.MN 55792 3 220 Bellaire Avenue Two Harbors 218-749-9405 MeritCare Clinic Wahpeton 332 2nd Avenue No. White Bear Lake.MW 55110 'Orthopedics W.St.Paul Wahpeton.ND 58075 612-777-5235 Orthopaedic Associates of 701-642-7000 Willmar Duluth,P.A. !Physical Therapy I Mental Health Services I1thAvenue&4th Family Physical Therapy of MeritCare Clinic Wahpeton 'Oral/Dental Surgery Two Harbors,MN 55616 West St. Paul 332 2nd Avenue No. Wang,DDS,P.A.,Joseph H. 218-834-7210 60 East Marie Ave,Suite 105 Wahpeton.ND 58075 1101 First SL South W.St.PauL MN 55118 Virginia 701-642-7000 Willmar,MN 56201 612-451-6156 Podia t 612-235-7290 !Dermatology ry Waconia MeritCare Clinic Wahpeton Woodbury East Range Clinics,Ltd. 332 2nd Avenue No. 910 N.6th Ave. Gastroenterology Wahpeton.ND 58075 !Dermatology Virginia.MN 55792 Lakeview Clinic, Ltd. 701-642-7000 River Valley Clinic,P.A. 218-741-0150 424 Hwy.5 West 8450 City Centre Drive General Surgery I Waconia,ShV 55387 Wayzata Woodbury,:&V 55125 East Range Clinics,Ltd. 612-442-4461 �Ophthalmology I 612-731-9010 910 N 6th Ave. General Surgery Northwest Eye Clinic,P.A. Orthopedics Virginia,.NN 55792 Lakeview Clinic,Ltd. 250 No.Central Ave.,Suite 107 Landmark Orthopedics,Ltd. 218-741-0150 424 Hwy.5 West Wayzata.MN 55391 2056 Woodlane Drive !Mental Health Services Waconia,MN 55387 612-473-1216 Woodbury,MN 55125 Range Mental Health Center 612-442-4461 Orthopedics I 612-735-9502 624 South 13th St Ophthalmology I St Croix Orthopedics,P.A. Orthopaedic Consultants,P.A. Virginia.AVANT 55792 Eye Physicians&Surgeons, 250 Central Ave.No.,Suite 303 20251Voodlane Drive,Suite 200 218-749-2881 P.A. IN Woodbury.AVANT 55125 Neurology I 550 So.Maple 6 612-176-0042 612-738-9586 East Range Clinics,Ltd. Waconia,MN 55387 Ortho edits:Hand Sur e 612-442-4445 Orthopedic Surgeons,Ltd. P 9 910N.6th Ave. 250N.Central Ave.#205 Landmark Orthopedics,Ltd. Virginia.NEV 55792 Lakeview Clinic,Ltd. Wayzata,Mg 55391 2056 Woodlane Drive 218-741-0150 424 Hwy.5 West Waconia..L1N 55337 612-449-9192 Woodbury..t'V 55125 Ophthalmology I 612-735-9502 East Range Clinics,Ltd. 612-442-4461 White Bear Lake Physical Therapy 910.V.6th Ave. :Orthopedics Mental Health Services I Family Physical Therapy of Virginia.MN 55792 Lakeview Clinic,Ltd. MinnHealth,P.A. Woodbury Hwy. West 218-741-0150 424 H S W 4736 Banning Avenue 2056 Woodlane Drive Waconia.MN 55387 Orthopedics White Bear Lake.MY 55110 Woodbury,.iAV 55125 612-442-4461 612-731-2286 East Range Clinics,Ltd. 612-426-6402 910 N.6th Ave. Orthopaedic Consultants,P.A. Orthopaedic Sports,Inc. 501 So.Maple Physical Therapy Virginia—1,NV 55792 Waconia.AV 55387 Family Physical Therapy of 2025 Woodlane Dr.,Suite 100 218-741-0150 White Bear Lake Woodbury,ALAV 55125 Otolaryngology 612-442-2163 1310 East Hwy.96.Suite 209 612-738-8270 4Podiafry i White Bear Lake..i4W 55110 East Range Clinics,Ltd. Zumbrota 91 0 N.6th Ave. Lakeview Clinic,Ltd. 612-426-7714 424 Hwy.5 West I General Su e virginia.Ndv 55792 Physical Therapy-FCE/ r9 Surgery Waconia.MV 55387 218-741-0150 612-442-1161 WH Interstate Medical Center- !Physical Therapy Family Physical Therapy of Zumbrota Iron Range Rehabilitation Wahpeton White Bear Lake 525 Mill Street , Center 1310 East Hwy.96,Suite 209 Zumbrota,M+1 55992 _ 1001 N.9th Ave !Dermatology White Bear Lake.MN 55110 507-732-7314 Virginia,A,411 55792 612-426-7714 Mental Health Services 218-749-9405 ',Podiatry Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 21 1 Interstate Medical Center- - Zumbrota 525 414111 Street Zumbrota,AN 55992 507-732-7314 "Neurology Interstate Medical Center- Zumbrota 52511,1111 Street Zumbrota,MN 55992 507-732-7314 Orthopedics Interstate Medical Center- Zumbrota 5 25,14111 Street Zumbrota.MN 55992 507-732-7314 Preferred WorkCare Specialist and Supportive Providers 21-Jun-94 22 i Prefer•WorkCare Hospitals by City. Employees covered by Preferred WorkCare are requested to use the following PreferredOne hospitals. Albany Area Hospital Chisago Health Services Hudson Memorial Hospital Holy Family Hospital 300 3rd Avenue Hospital 400 Wisconsin EL 535 Hospital Rd Albany.MW 56307 11685 Lake Blvd North Hudson.WI 54016 New Richmond,WI 54017 612-845-2121 Chisago City,MN 55013 715-386-9321 715-246-2101 Douglas County Hospital 611-257-8400 Hutchinson Community Northfield Hospital 111 17thAve.E Mercy Medical Center Hospital 801 W.1st St. Alexandria,MN 56308 4050 Coon Rapids Blvd 1095 Hwy.15 S. Northfield,MN 55057 612-762-1511 Coon Rapids,MN 55433 Hutchinson.MV 55350 5074454661 Memorial Medical Center 611-421-8888 612-587-2148 Mille Lacs Health System I615 Maple Lane St. Mary's Regional Health Meeker County Memorial 200 N.Elm St. Ashland.WI 54806 Center Hospital Onamia.MN 56359 71 5-682-4563 1027 Washington Ave. 613 Sibley Ave.S. 612-531-3154 White Community Hospital Detroit Lakes,IN 56501 Litchfield MV 55355 h' os p PaynesviIle Area Health Care 218447-5611 612-693-3242 System Aurora.MN 55792 St. Luke's Hospital St. Gabriel's Hospital 200 First St. 218-229-2211 915 East First Street 816 S.E.Ind Si. Paynesville.MN 56362 North Country Hospital Duluth.114N 55805 Little Falls.MN 56435 612-243-3767 1100 W.38th St. 218-726.5555 612.631-5441 Perham Memorial Hospital Bemidji..kQV 56601 Fairview Southdale Hospital Melrose Hospital 665 3rd St SW 318-751-5430 - 6401 France Ave.So. 11 N.5th Ave.W. Perham,MW 56573 United Hospital District Edina,MN 55435 Melrose.MW 56352 218-346-4500 611-914-5000 612-256.4231 515 South Moore Fairview Northland Regional Blue Ea 56013 Fairmont Community Fairview Riverside Medical Hospital Hospital Center 507-526-7371 704 First St. 835 Johnson St. Riverside at 25th Ave.So. Princeton.414V 55371 St.Francis Medical Center Fairmont.MN 56031 Minneapolis.MV 55454 612-389-1313 415 Oak St 507-238-4254 612-672-6000 Breckenridge..kMV 56520 St.John's Regional Hospital 1 District Memorial Hospital University of Minnesota 1401 W Fourth 18-643-3000 246 11th Ave.SE Harvard St at East River Rd. Red Wing,lkAr 55066 Buffalo Hospital Forest Lake,MV 55025 Minneapolis.MN 55455 612-388-6721 303 Catlin Si. 612-464-3341 612-626-3899 Buffalo,IN 55313 River Falls Area Hospital Unity Medical Center Monticello-Big Lake 1629 E Division St. 612-473-1652 550 Osborne Rd. Community Hospital Fairview Ridges Hospital River Falls,WI 54022 Fridley,.41N 55432 1013 Hart Blvd 715-425-6155 201 East.Vicollet Blvd 612-421-2222 Monticello,MN 55362 Burnsville..1LV 55337 North Memorial Medical 612-295-2945 Glacial Ridge Hospital 6t_ Center 612492-2000 IOS.E 4th Ave. Mercy Hospital 3300 Oakdale Ave.North Cambridge Memorial Glenwood NW 56334 710 Kenwood Ave. Robbinsdale,.41N55422 Hospital 612-634-4521 Moose Lake,MN 55767 612-520-5200 725 So.Dellwood Cambridge,I N 55008 Itasca Medical Center 218-485-4481 St. Cloud Hospital 612-689-1500 126 First Ave.S.E. Kanabee Hospital 1406 6th Ave.N. Cannon Falls Community Grand Rapids,NW 55744 300 Clark St St.Cloud,MN 56303 Hospital 218-326-3401 Mora.1.4W 55051 612-251-2700 111611111 St W Regina Memorial Hospital 612-679-1212 St. Croix Valley Memorial Cannon Falls,NEV 55009 NinigerRd Queen of Peace Hospital 507-263-4221 Hastings.MN 55033- 301 2nd St.N.E. 204 Adams St. 612-437-3121 New Prague,MY 56071 St.Croix Falls.WI 54022 612-758-4431 715-483-3261 Preferred WorkCare Hospitals 21-Jun-94 23 Pribred WorkCare Hospitals by (* Employees covered by Preferred WorkCare are requested to use the following PreferredOne hospitals. United Hospital 333 North Smith Ave. St.Paul MV 55102 612-220-8000 Lakeview Hospital 919 W.Anderson St. Stillwater,MN 55082 612-439-5330 Superior Memorial Hospital 3500 Tower Ave. Superior,WI 54880 715-3924281 Virginia Regional Medical Center 901 N 9th St Virginia..4W 55792 218-741-3340 Ridgeview Medical Center 500 S.Maple St. Waconia,.t EV 55387 612-442-2191 Tri-County Hospital 418 N.Je11"erson Wadena.MN 56482 218-631-3510 Zumbrota Hospital 383 W.5th St Zumbrota..LIN 55992 507-732-5131 Preferred WorkCare Hospitals 21-Jun-94 24 f .• - Preferred WorkCare Provid.irectory -All Providers by Splty by City 21-Jun-94 Cardiology 12445 River Ridge Road Bunuville,MN 55337 612.94.7620 524 NW 3rd Avenue Grand Rapids,MN 55744 218-32640= Cambridge Hibbing Duluth Cambridge Chiropractic Vechell-Michaels Chiropractic Duluth Clinic 141 SW 2nd Avenue Cambridge,MN 55008 612-689-2462 115 West Howard St Hibbing,MN 55746 218-262-3315 400 East 3rd St Duhtth,MN 55805 218-725-3156 Chanhassen Hutchinson Fargo Chanhassen Chiropractic Kamrath Chiropractic 680 W.78th Street Chanhassen,MN 55317 612-934-4500 717 Shady Road Hutchinson,MN 55350 612-587.3888 MeritCare Medical Group 737 Broadway Fargo,ND 58123 701-234-2000 Cloquet Inver Grove Heights Forest Lake Benson Chiropractic Clinic Inver Grove Chiropractic Forest Lake Doctors Clinic 807 Cloquet Avenue Cloquet,MN 55720 218-879.6049 6506 Cahill Are.Inver Grove Heights,MN 55075 612-151-1012 121 SE I1thAvenue Forest Lake,MN 55025 612-164-7100 Cold Spring Isle Hugo First Chiro Cold Spring Mille Lacs Chiropractic Hugo Medical Clinic 402 Red River Ave.N.$3 Cold Spring,MN 56320 612-685-8284 275 West Main St Isle.MN 56342 612.676-3501 14145 North Forest Blvd.Hugo,MN 55038 612426.9216 Columbia Heights Lake City Mankato Heights Chiropractic Lake City Chiropractic Mankato Clinic 4111 Central Ave.N.E Columbia Heights,MN 55421612.788-0515 127 3.High Lake City,MN 55041 612-345-3361 1230 East Main St Mankato,MN 56002 507.625-1811 Coon Rapids Lakeville Maplewood Coon Rapids Chiropractic Clinic Dakota Chiropractic Clinic St.Faul Heart Clinic 330 Nonhdale Blvd.Coon Rapids,MN 55433 612.755-4300 17787 Kenwood Trail Lakeville,MN 55044 612-435-3345 1675 Beam Ave 4101 Maplewood,MN 55109 612-779-9444 Crookston Maple Grove St.Paul Biermaier Chiropractic Clinic Maple Grove Family Chiropractic Affiliated Cardiovascular Consultants,P. , 1226 University Ave,Box 496 Crookston,MN 56716 218-281.6311 13704 Grove Dr.Maple Grove,MN 55369 612-420-5200 360 Sherman St#250 St Paul,MN 55102 612-292-9914 Duluth Melrose SL Paul Heart Clinic Fisher Chiropractic Melrose Chiropractic 255 No.Smith Avenue$100 St Paul MN 55102 612-292-0616 1118 E.Superior St.Duluth,MN 55802 218-728.3639 109 So rat Ave West Melrose,MN 56352 612-256.4692 Eagan Milaca Chiropractic Eagan Chiropractic Fogel Chiropractic Albany 1565 ClifiRd.Eagan.MN 55122 612-688-0462 105 S.Central Milaca,MN 56353 612-983-6805 Davis Chiropractic Clinic Eden Prairie Minneapolis Pa Box 600 Albany,MN 56307 612-845.4850 Ecklund&Ecklund Chiropractic Calhoun Chiropractic Alexandria 561 Prairie Center Dr.Eden Prairie,MN 55344 612-943-1188 1620 Lake Sheet Minneapolis,MN 55408 612.822-5973 Peterson Chiropractic Edina Forsgren Chiropractic 1 106 Broadway Alexandria MN 56308 612.762 8671 Hammond Chiropractic 2546 Cenral Avenue NE Minneapolis,MN 55418 612-781-1725 Annandale 6950 France Ave.S.Edina,MN 55435 612-922-3770 Northwestern College of Chiropractic Family Chiro Centers Elk River 2929 Bloomington Avenue Minneapolis,MN 55407 612-721-5738 Rafferty Chiropractic The Cities Chiropractic Center 25 Bagley Street West Annandale,MN 55302 612-274-3060 800 Nieollet Mall $540 Minneapolis 141155402 612.333.9144 Bagley 653 Main Street Elk River,MN 55330 61--441 2411 Bagley Chiropractic Fairmont Monticello Lund Chiropractic Clinic Monticello Chiropractic Clinic 103 ClorataAve No Bagley,MN 56621218.684-6253 212 Cedar Street Monticello,MN 55362 612-295-2262 Baypport 118 West Second St Fairmont,MN 56031507-235-3331 Fargo Moorhead Wieners Chiropractic Ihy Chiropractic Larurn-Pladson Chiropractic 324 No.5th SL Bayport,MN 55003 612439-7621 1330 Page Drive Fargo,ND 58103 701-232-1232 Moorhead Center Mall Moorhead,MN 56560 218.236.5151 Bemidji Faribault Mora Hanson Chiropractic Mora Chiro ractic Clinic 702 Sth Street NW Bemidji,MN 56601218-751.9633 Silly-Navaho Chiropractic P 127 NW 4th St Faribault,MN 55021507-334.3251 119 Lake St.Mom,MN 55051 612-679-1133 ' Bloomington Forest Lake New Hope Lindberg Chiropractic Forest Lake Chiropractic Falk Chiropractic 726 W.98th St Bloomington,MN 55420 612-881-4421 2738 Wetka Ave.N.New Hope MN 55427 612.5468622 Northwestern College of Chiropractic 591 N.Shore Drive Forest!rake MN 55025 612-164 2133 buh Frederic New Prague 2501 went 84th street Bloomington,MN 55431 612-885-5444 Lauritsen Chiropractic Neck and Back Clinic of New Prague Valley West Chiropractic P 10700 Nottnandale Blvd.Bloomington, 55438 612-888-5805 301 Ash Street Frederic,WI 54837 715-3274253 201 East Main.Box 82 New Prague,MN 56071 612-758 5135 Fridley New Richmond Brainerd y Crow Wing Chiropractic Kramber Chiropractic Clinic Vrieze Chiropractic =0 W Washington Brainerd MN 56401218-8294414 1299 Mississippi St NE Fridley,MN 55432 612-571-4148 150 West 1st St New Richmond,WI 54017 715-246-7000 Glencoe North Mankato Brooklyn Park Chiropractic,e Dh tactic,Ltd. Brook West Chiropractic Clinic Gasser Chiropractic P 1706E 10th St Glencoe,MN 55336 612-864-3196 1'706 Lot Ray Drive North Mankato,MN 56003 507-388-'1744 6800 78th Ave.N.Brooklyn Park,MN 55445 612-566-1042 Northfield Buffalo Golden Valley Valley Square Chiropractic Goehtz Chiropractic Family Centers 205 Division Street Northfield,MN 55057 507-645 8242 110 Division Street Buffalo,MN 55313 612-682-1471 7500 Olson MemotialHwy.Golden Valley,MN 55427 612-5454600 Burnsville Grand Rapids Oakdale Garth Chiropractic Clinic Northwestern College of Chiropractic Simonson Chiropractic P 1041 Geneva Aver=Nods Oakdale,MN 55128 612-731-19 53 Preferred WorkCare:All Providers by Specialty 21-Jun-94 25 • •s Perham 0 Winsted 41,ctrodiagnostics- EMG -, Perham Chiropractic Nygren Chiropractic _ R43 Box 23 Perham.MN 56573 218-346-2330 111 2nd St M.Winced,MN 55395 612-485-3700 Edina Pine City Woodbury Bland,M.D.,Charles S. Knox Chiropractic Back and Neck Pain Clinic 6545 France Ave.S.o.4323 Edina.MN 55435 612.9264165 ',such Hwy.61,Box 4 Pine City,MN 55063 612-629-6717 1502 Woodlane Dr.Woodbury,MN 55125 612-735-8653 lilsson Chiropractic Emergency Medicine 153 5th Street Pine City,MN 55063 612629.2740 Dermatology Duluth Prescott Buffalo Duluth Clinic Williamson Chiropractic Buffalo Clinic,P.A. 400 East 3rd 5t Duluth,MN 55805 218-725-3156 218 Broad St N.Prescott,WI 54021 715-262-3661 1700 Highway 25 N.Buffalo,MN 55313 612.682.1313 Urgent Care-ReadyCare St.Luke's Hospital Princeton Cambridge 915 East 1st St Duluth,MN 55805 218.726-5555 Princeton Chiropractic Professional Medical Assoc(Cambridge Clinic) Fargo 501 South 4th Stmt Princeton,MN 55371 612-389-4411 626 SW 7•1 Avenue Cambric :•1 Prior Lake Cambridge,MN 55008 612-689-1411 MeritCare Medical Group Chisago City 737 Broadway Fargo,ND 58123701-234-2000 Behm Chiropractic Chisago Health Services Fridley 4646 Colorado Street SE Prior Lake,MN 55372 612-447.3516 1 1685 Lake Blvd.North Chisago City,MN 55013 612-257-8400 Fridley Medical Center Red Wing Coon Rapids 7576 Madison St NE Fridley,MN 55432 612-785-4500 Downtown Chiropractic Associated Skin Care Specialists,P.A. Hudson 419 W.3rd Red Wing,MN 55066 612.388-3212 3960 Coon Rapids Blvd.8116 Coon Rapids,MN 55433 612-571.4000 Hudson Physicians,Ltd. Richfield Coon Rapids Medical Center 400 Wisconsin Street Hudson,WI 54016 715-386-8880 Costanzo Chiropractic 9055 Spdngbrook Dr.Coon Rapids,MN 55433 612-780-9155 Minneapolis 6519 Nicollet Avenue 0201 Richfield,1C455437 612861.6605 Duluth Airport Medical Clinic River Falls Duluth Clinic 7775 26th Avenue South Minneapolis,MN 55450 612-7264771 Kinnikinic Chiropractic 400 East 3rd St Duluth,MN 55805 218-725.3156 Family Practice 300 N.River St River Falls,WI 54022 715-425-2846 Eden Prairie Robbinsdale Associated Skin Care Specialists,P.A. Alexandria Northwestern College of Chiropractic 8455 Flying Cloud Dr.8105 Eden Prairie,MN 55344 612-571-4000 Alexandria Clinic,P.A. 3605 France Avenue No.Robbinsdale,MN 55422 612-588-4618 Forest Lake 610 Fillmore St.PO Box 1149 Alexandria,MN 56308 612-763-5123 Sauk Centre - Forest Lake Doctors Clinic Sauk Center Chiropractic Thompson,M.D.,Michael B. P 121 SE 11th Avenue Forest Lake,MN 55025 612-464-7100 1600 South Broadway Alexandria,MN 56308 612-762-2371 519 So Main St Sauk Centre,MN 56378 312352.6889 Fridley Annandale Spring Lake Park Associated Skin Care Specialists,P.A. Annandale Family Physicians Spring Lake Park Chiropractic 500 Osborne Road NE 8330 Fridley,MN 55432 612-571-4000 55 No.Maple Avenue Annandale,MN 55302 612-274-3744 •1 Hwy 10 NE Spring Lake Park,MN 55432 612-784-1540 7205 University Ave NE Fridley,MN 55432 612-571-4000 Anoka i.Cloud Glencoe Mork Clinic East Side Chiropractic Glencoe Medical CIinic,PA. 1833 2nd Avenue South Anoka,MN 55303 612-421-3680 22 NE Wilson/119 St Cloud,MN 56304 612-251-3303 525 18th Street East Glencoe,MN 55336 612-864-3116 Aurora West Side Chiropractic Hastings 4142 2nd Street South St Cloud,MN 56301 612-255-5188 River Valley Clinic,P.A. East Range Clinics-Aurora 405 W 3rd Ave Aurora,MN 55705 218.229-3311 St.Croix Falls 1210 W.Fast St.Hastings,MN 55033 612-1384800 Babbitt Boat Chiropractic Hugo 144 N.Adams St St Croix Falls WI 54024715-483-3913 Ely Medical Center-Babbitt(Duluth Clinic) Hugo Medical Clinic 45 North Drive Babbitt,AN 55731 2 18-327-2176 St.Paul 14145 North Forest Blvd.Hugo,MN 55038 612.426-9216 Bagley Hynan Chiropractic Hutchinson MeritCare Clinic Bagley 475 University Ave.W.St Pant MN 55103 612-.'x'2.1331 Hutchinson Medical Center.P.A. 123 Fourth Street NW Bagley,MN 56621 218-694-2384 Northwestern College of Chiropractic 3 Century Avenue Hutchinson,MN 55350 612-587-2020 Bemidji 621 So.Cleveland St Paul,MN 55116 612-690.1788 Mankato Stillwater Mankato Clinic MeritCare Clinic Bemidji Spore Chiropractic 1233 34th Street NW Bemidji,MN 56601218-759-5000 p 1230 East Main St Mankato,MN 56002 507-625-1811 Blaine 5898 OumhiAvenue Noah Stillwater,MN 55082 612-4394013 Monticello Vadnais Heights Hart Medical Clinic Blaine Medical Center Jackson Chiropractic 200 12175 Aberdeen St NE Blaine,MN 55434 612-785-4200 p Sandberg Road Monticello,MN 55362 612-295-4060 Bloomington 3508 N.Rice St.Vadnais Heights,MN 55126 612-183-4321 Northfield HealthWorks Virginia River Valley Clinic,P.A. 600 West 98th St,Suite Chiropractic 1400 Jefferson Northfield,MN 55057 507-645-2000 ite 395 Bloomington,MN 55420 612-885-6170 301 So 4th St Virginia,Nor 55792218-741-3402 Soderville Blue Earth Waite Park Blue Earth Medical Center Crosstown Medical Clinic 520 South Galbraith Blue Earth,MN 56013 507-526-7371 Ellingson Chiropractic Clinic 17615 Chisholm Street Soderville,MN 55304 612-434-9040 Braham 49 2nd Avenue North Waite Park,MN 56387 612.251.3828 Virginia Miner Chiropractic Clinic East Range Clinics,Ltd. Braham Clinic 110 S.2nd St,X214 Waite Park,MN 56387 612-253-5650 112 NW 5th Street Behar.MN 55006 612-396-3341 910 N.6th Ave.Virginia,MN 55792 218-741-0150 Wayzata Wahpeton Brooklyn Center 'Wayzata Chiropractic MeritCare Clinic Wahpeton Northport Medical Center,Ltd. .5 Ferndale Ave.So.Wayzata,MN 55391 612-473.4241 5415 Brooklyn Blvd.Brooklyn Center,MN 55429 612-533-8666 332 2nd AvenueNo.Wahpeton.ND58075701-542-7000 Brooklyn Park White Bear Lake Woodbury Jensen Chiropractic River Valley Clinic,P.A Brooklyn Park Medical Center 1310 Hwy.96,8102 White Bear Lake,MN 55110 612-429-5329 8450 C' Centre Drive Woodb 5805 74th Ave.North Brooklyn Park,MN 55443 612-572-5700 City ary,MN 55125 612'31-9010 Preferred WorkCare: All Providers by Specialty 21-Jun-94 26 • . .r . Buffalo Grand Ave Duluth,MN 55807 218-725-3513 Haw Buffalo Clinic,P.A. 1�Clinic-Lakeside Ha edical Center 1700 Highway N.Buffalo,M4 55313 612.682-1313 Superior St nth.MN 55804 218-525-7487 1413 Buffalo Family&Specialty Care Center,PA. St.Luke's Occupational Health Svc. Hillma Hawley,MN 56549 218 183-3564 303 Catlin Buffalo,MN 55313 612.682.5225 915 Eau Fast Street Duluth,MN 55805 218-726.5345 Milk Lacs Family Clinic Burnsville Eden Prairie 3603rd Avenue Hilhmn,MN56338612.277.3682 Burnsville Family Physicians Eden Center Family Physicians Hinckley 12940 HametAve.South Burnsville,MN 55337 612-894-9700 830 Prairie Cir.Dr.4180 Eden Prairie,MN 55344 612.946-0947 Mora Medical Center-Hinckley Cambridge Edina 302 Fire Monument Hinckley,MN 55037 612-384-6189 Occupational Medicine-Cambridge Hospital Edina Family Physicians Hudson 725 South Dellwood Cambridge,MN 55008 612.689-7777 5203 Vernon Ave.South Edina,MN 55436 612-925-2200 Hudson Physicians,Ltd. Professional Medical Assoc(Cambridge Clinic) Elk River 400 Hudson Street Hudson,WI 54016 715-386-8880 626 SW 7lhAvenue Cambridge,MN 55008 612-6894411 Mork Clinic Hugo Cannon Falls 530 3rd Sheet Ells River,MN 55330 612.441-3660 Hugo Medical Clinic Cannon Family Health Center Rum River Medical Associates-Elk River 14145 North Forest Blvd.Hugo, West Mill Street Cannon Falls,MN 55009 507-263-3951 290 Main Street Northwest Elk River,MN 55330 612-241-0373 go.MN 55038 612-126 9216 Hutchinson Cass Lake Ellsworth Hutchinson Medical Center,P.A. MeritCare Clinic Cass Lake Interstate Medical Center 3 Century Avenue Hutchinson,Medical Center, MN 55350 612.587-2020 RR),Box 1 Cass Lake,MN 56633 218.335-2559 230 Cairns Street EllSWOtth,W154011 715-273-5061 Isle Champlin Ely Milk Lacs Family Clinic Champlin Medical Center Ely Medical Center(Duluth Clinic) 360 3rd Avenue South isle MN 56342 612-676-3661 11269 Jefferson Hwy.Champlin,MN 55316 612.427-9620 224 East Chapman St Ely,MN 55731 218-365-3151 Jordan Chanhassen Eveleth Jordan Medical Clinic,Ltd. Chanhassen Medical Center East Range Clinics-Eveleth 506 W.2nd St Jordan MN 55352 612 492-3100 470 W.78th St.,PO Box 423 Chanhassen,MN 55317 612.934-0570 239 McKinley Ave Eveleth,MN 55734 218-7443472 Evansville Lake Crystal Chaska Mankato Clinic Valley Family Practice Evansville Clinic 221 South Murphy Lake Crystal,MN 56002 507-726-2136 822 Yellow Brick Rd.Chaska,MN 55318 612-448-3303 109 Main Street Evensville,MN 56326 218-948-2234 Lake Elmo Chisago City Fargo Mitu Health,P.A. Chisago Health Services MeritCare Clinic North Fargo 11240 Stillwater Blvd.Like Elmo,SLY 55042 612-777-9363 11685 Lake Blvd.North C.tisago City,MN 55013 612-2574400 2601 Broadway Fargo,ND 58012 701-234-2900 Lakeville Clearbrook MeritCare Clinic Southpointe fi Lakeville -Dodd Medical Clinic MeritCare Clinic Clearbrook 2400 32nd Avenue So.Fargo ND 58104 701.234 8800 20157 lcenio d-Doakeville,MN 55044 inic 69-3393 Elm Street Clearbrook,MN56634218-776-3124 MeritCare Clinic Southwest Lester Prairie Clearwater 2701 13th Avenue South Fargo,ND 58103 701.234-3600 MertiCare Broadway Health Centre Lester Prairie Medical Clinic St.Cloud Medical Group-Clearwater 23 Hickory Street No.Lester Prairie,MN 55354 612-395-2527 615 Nelson Drive Clearwater,MN 55320 612-558-2293 736 Broadway Fargo,ND 58123 701-234-2000 Farmington Litchfield Cokato Litchfield Medical Clinic River Valley Clinic,P.A. Litchfield Clinic-Cokato 611 S.Sibley Ave Litchfield,MN 55355 612.693-2804 770 South Broadway Cokato,MN 55321 612.286 2123 910 Main Street Farmington,MN 55024 612-463-7181 Floodwood Little Falls Columbia Heights Family Medical Center,PA Columbia Park Clinic Floodwood Community Clinic(Duluth Clinic) 811 SE 2nd Sheet Little Falls,MN 56345 612-632.6611 Floodwood,MN 55736 218476-2=1 4000 Genital Avenue NE Columbia Heights,MN 55421612-572-5700 Mankato Coon Rapids Foley Mankato Clinic Coon Rapids Medical Center Foley Medical Center,Ltd. 400 No.Broadway Foley,MN 56329 612.968-72234 1230 East Main St Mankato,MN 56002 507-6254811 9055 Springbrook Dr.Coon Rapids,MN 55433 612-780-9155 Maple Grove Family Medicine Clinic Forest Lake Camden Physicians,Ltd.-Grove Square Office 3960 Coon Rapids Blvd.Suite 100 Coon Rapids,MN 55433 612-422-4 Ceman,M.D.,Chris P. 79 N.Lake Street Forest Lake,MN 55025 612.464-7706 13800 83rd Way Maple Grove,MN 55369 612-420-5822 Cottage Grove Maple Grove Medical Center River Valley Clinic,PA. Forest Lake Doctors Clinic 121 SE 1 1 thAvenue Forest Lake,MN 55025 612.464-7100 13986 Maple Knoll Way Maple Glove MN 55369 612-120 3700 8451 SE Point Douglas Rd.Cottage Grove,MN 55016 6124584884 Mapleton Crystal Fridley Mankato Clinic Bass Lake Physicians Fridley Medical Center 305 Main St East 5707 West Broadway Crystal,MN 55429 612-537 6022 7576 Madison St NE Fridley,MN 55432 612-785-4500 Mapleton MN 56002 507-5243835 Fridley Plaza Clinic Maplewood Northwest Family Physicians,P.A. MinaHeaith,P.A. 5502 W.Broadway Crystal,MN 55428 612-537 8473 6341 Universiry Ave.NE Fridley,MN 55432 612-572-5110 Glencoe 2716 Upper Alton Road Maplewood,MN 55119 612-739-4599 Deer River 1814 N.St Paul Road Maplewood,SLY 55109 612-777-0298 Deer River Community Clinic(Duluth Clinic) Glencoe Medical Clinic,P.� Melrose 325 18th Street East Glencoe,MN 55336 612-864-3116 Melrose prose Clinic,PA 1002 Comstock Drive Deer River,MN 56636 218-246.8275 Golden Valley Detroit Lakes 603 West Main Sheet Melrose,MN 56352 612.256-1228 Golden Valley Clinic,Ltd. MeritCare Clinic Detroit Lakes Milaca 1245 S.'Washington Detroit Lakes,MN 363012184146-2000 8240 Golden Valley Rd.Golden Valley,MN 55427 612-545-1445 m Halsted Ru River Medical Associates-Milaca Duluth 150 10th Street NW,Suite B Milata MN 56353 612-983.6101 MeritCare Clinic Halsted Duluth Clinic Minneapolis 400 East 3rd St Duluth.MN 35805 218 723-3136 224 2nd Avenue West Halsted,MN 56548 218-436.2158 Hastings Camden Physicians,Ltd.-Camden Office Duluth Clinic-Hermantown 1206 No.42nd Avenue Minneapolis,304 55412 612-522.6601 4886 Miller Trunk Highway Duluth,MN 55811218-727-8119 River Valley Clinic,P.A. 1210 W.First St.Hastings,MN 55033 6124384800 Family Medical Clinic-Fairview Clinics Duluth Clinic-West 3809 42nd Ave so Minneapolis, 55406 612-721.6261 Preferred WorkCare: All Providers by Specialty 21-Jun-94 27 Family Medical Clinic NE-Fairview Clinics Ramsey er ., 2849 Johnson St NE Mmneapoils,MN 55418 612-781.6646 , Ramsey Medical Center •Medical Center-Tower(Duluth Clinic) Health Worsts 5300 153rd Ave.NW Ramsey,MN 55303 612-421-7180 Mail street Tower.MN 55790 218-753-6161 3033 Uoiveeity Ave.SE Minneapolis,MN 55414 612.379-7244 Red Wing Virginia Northeast Medical Clinic Interstate Medical Center East Range Clinics,Ltd. 1229 2nd St NE Minneapolis,MN 55413 612.379-1119 2835 3,Service Drive Red WOOL MN 55066 612.388-3503 910 N.6th Ave.Virgytir,MN 55792 218-741-0150 Silver Lake Clinic Interstate Medical Center- Waconia 100 Stinson Blvd.NE Minneapolis,MN 55421 612.1884565 434 West 4th Street Red Wing,MN 55066 612-388.6749 Lakeview Clinic,Ltd. South Medical Clinic Remer 424 Hwy.S West Waconia.MN 55387 612-442-4461 4310 Nicollet Ave.South Minneapolis,MN 55409 612-827-3503 Deer River Community Clinic-Reiner(Duluth C Wahpeton Monticello Box 157 Rainer,MN 56672 218-5664441 Hart Medical Clinic MeritCare Clinic Wahpeton Richmond 332 Ind Avenue No.Wahpeton,ND 58075 701-642-7000 200 Sandberg Road Monticello,MN 55362 612.295-1060 Richmond Medical Clinic Watertown River Place Family Physicians 21 Ivy Avenue SE Richmond,MN 56368 612.597-2122 Lakeview Clinic,Ltd. 1101 Hatt Blvd.,Suite 210 Monticello,MN 55362 612.295-3200 Robbinsdale 309 Jeffe,on Ave.SW Watertown,MN 55388 612.955-1921 Moorhead Northwest Family Physicians,P.A. White Bear Lake MeritCare Clinic Moorhead 5810 42nd Ave.North Robbinsdale,MN 55422 612-531.8405 MinnHealth,P.A. 1301 8th Street So.Moorhead,MN 56560 701-234-3200 Rosemount 4786 Barring Avenue White Beat Lake,MN 55110 612-426-6402 Mora Mora Medical Center Rosemount Family Physicians 3220 Bellaire Avenue White Bear Lake,MN 55110 612-777-5235 15120 Chippendale Rosauomtt MN 55068 612-423-4114 Winnebago 224 Seventh St Mora MN 55051 612-6794313 Rosemount Medical Clinic Winnebago Medical Center-Blue Earth Med Ctr New York Mills 14450 3.Roberts Tt Rnsernomtt MN 55068 612-423-1168 115 l st Ave NW Winnebago,MN 56098 507-893-3144 MeritCare Clinic New York Mills Roseville Woodbury 209 Tousley New York Mills,MN 56567 218-385-2555 MinnHealth,P.A. River Valley Clinic,P.a. North Branch 1050 W.IarpenteurAvenue Roseville,MN 55113 612-487-1615 8450 City Centre Drive Woodbury,MN 55125 612-731-9010 Chisago Health Services Rosedale Medical Center Wyoming 7th and Oak North Branch,MN 55056 612-574-8353 2393 Fairview Ave.N.Roseville,MN 55113 612-785-4300 Wyoming Medical Center North Mankato Roseville Family&Industrial Clinic,PA. 5350 266th St Wyoming MN 55092 612-462-1515 Mankato Clinic 2215 North Snelling Roseville,MN 55113 612-646-7516 Zimmerman 1875 Lookout Drive North Mankato,MN 56001 507.625-5027 Savage Rum River Medical Associates-Zimmerman North Ridge Family Medicine Clinic,-P.A. Sundance Medical Clinic,Ltd. 12980 Fremont Avenue Zirrmerrtan,MN55398612.856-4604 1695 LorRay Drive North Mankato,MN 56003 507-387-8231 4011 West Highway 13 Savage,MN 55378 612490-1555 Zumbrota Northfield Shakopee Interstate Medical Center-Zumbrota River Valley Clinic,P.A. Sundance Medical Clinic,Ltd. 525 Mill Street Zumbrota,MN 55992 507.732.7314 1400 JeffeesonNottlt5ekl,MN 55057 507-645-2000 323 Nawnkeag St.Shakopee,MN 55319 612-445-6440 orwood Shoreview Gastroenterology Lakeview Clinic,Ltd. Silver Lake Clinic Buffalo 522 Faxon Rd Norwood,MN 55368 612-481-2888 4625 Churchill St 8110 Shoreview,MN 55126 612.481-0818 Onamia Buffalo Family&Specialty Care Center,P.- Soderville 303 Carat Buffalo,MN 55313 612-682-5225 Mille Lacs Family Clinic Crosstown Medical Clinic Duluth 201 Kathie St.Onamia,MN 56359 612432-4101 17615 Chisholm Street Sodetvills,MN 55304 612-434-9040 Osakis Duluth Clinic Solon Springs 400 East 3rd St Duluth,MN 55805 218-725-3156 Osakis Medical Center Northwest Medical Center-Solon Springs I Highway 127,PO Box W Osakis,MN 56360 612459-3038 8 Northland Gastroenterology and Surgery,P.A. South Lake Ave Solon Springs,WI 54873 715.378.21_1 St.Lairds Hospital 3 East Duluth,MN 55805 218.725-6050 Osseo Spooner Hastings Osseo Clinic,P.A. Northwest Medical Center-Spooner(Duluth Cl River Valley Clinic.P.A. 226 CentralAve,Osseo,MN 55369 612-425.2117 707 Ash Street Spooner,WI 54801715.635-2151 1210 W.Frost St.Ratings,MN 53033 612-1384800 Paynesville St.Cloud Paynesville Medical Clinic,P.A. Mankato Midwest Occupational Medicine Mankato Clinic 310 Washburn Avenue Paynesvdle,MN 56362 612-243-3779 1545 Northway Drive St Cloud,MN 56303 612-251-9673 1230 East Main St Mankato,MN 56002 507-625-1811 Perham St.Cloud Medical Group,P.A. Maple Grove MeritCare Clinic Perham 1301 W.St Germain St Cloud,MN 56301 612.2514181 Camden Physicians,Ltd.-Grove Square Office 663 3rd Street SW Perham,MN 56573 218-346-4040 St.Michael 13800 83rd Way Maple Grove,MN 55369 612-420-5822 Pierz St.Michael Medical Center Northfield Community Medical Center 703 Thielen Drive St Michael,MN 55376 612-497-2979 River Valley Clinic,P.A. 200 South 1st Avenue Pier.MN 56364 612.468-2536 St.Paul Pine City MinnHealth. 1400 JedmonNotdtfield,MN 55057 507-645-2000 nnHealth.P.A.PA. Plymouth Mora Medical Center-Pine City 261 North Ruth Sava St Paul,MN 55119 612.738-9582 Camden Physicians,Ltd.-Four Seasons Office 220 3rd Ave Pine City,MN 55063 612.629-7505 Stewart Plymouth 9750 Rockford Road Plymouth,MN 55442 612 2559-3164 Y Stewart Medical Clinic Waconia Camden Physicians,Ltd.-Four Seasons Office 300 Bowumt Street Stewart,MN 55385 612-562-2558 Lakeview Clinic,Ltd. 9750 Rockford Road Plymouth,MN 55442 612-559-3164 Stillwater • 424 Hwy.5 West Waconia,MN 55387 612.442.4461 Northwest Family Physicians,P.A. Stillwater Clinic General Surge 495 Hwy.101 North Plymouth,MN 55447 612-476-6776 1500 Curve Crest Blvd.Stillwater,MN 55082 612-r39-1233 Surgery ✓ rinceton Superior Rum River Medical Associates-Princeton Duluth Clinic-Superior Alexandria 919 Northland Dave Princeton,MN 55371 612-389-3344 318 21st Ave East Superior,WI 54880 715-398.6921 Alexandria Clinic,P.A. 610 Fill ore St,PO Box 1149 Alexandria,MN 56308 612.7634123 Preferred WorkCare: All Providers by Specialty 21-Jun-94 28 .4 • Anoka 3 Ayes=Hutchinson.MN55350612.587.2020 Wah Mork Clinic an M Clinic Wahpeton 1833 2nd Avenue South Anoka MN 55303 612-421-3680 dance Medical Clinic,Ltd. 332 2nd Avenue No.Wahpeton,ND 58075 701-642-7000 _ Bemidji 506 W.Ind St Jordan.MN 55352 612.492.3100 Zumbrota MeritCare Clinic Bemidji Litchfield Interstate Medical Center-Zumbrota 1233 34th Street NW Bemidji,MN 56601 218-759-5000 Prashad,MD,Damush 525 Mill Street Zumbrota.MN 55992 507-732.7314 Blue Earth 611 Sibley Ave Litchfield,MN 55355 612.693-2804 Blue Earth Medical Center Little Falls Hospital 520 South Galbraith Blue Earth.MN 56013 507.526-7371 Little Falls Surgical Clinic , Buffalo 808 Southeast 3rd Street Little Falls,MN 56345 612.6324611 Alexandria Buffalo Clinic,P.A. Mankato Douglas County Hospital 1700 Highway 25 N.Buir le,MN 55313 612.682-1313 Mankato Clinic Ill 17th Ave.E.Alexandria,MN 56308 612.762-1511 Buffalo Family&Specialty Care Center,P.A. 1230 East Main St Mankato,MN 56002 507-6254811 Aurora 303 Catlin Buffalo,MN 55313 612-682-5225 Maple Grove White Community Hospital Cambridge Camden Physicians,Ltd.•Grove Square Office Aurora.MN 55792 218-229.2211 Professional Medical Assoc(Cambridge Clinic) 13800 83rd Way Maple Grove,MN 55369 612-420-5822 Bemidji 626 SW 7th Avenue Cambridge,MN 55008 612.689.1411 Minneapolis North Country Hospital Chisago City Camden Physicians,Ltd.-Camden Office Iwo W.38th St Bemidji,MN 56601 218751-5430 Chisago Health Services 1206 No.42nd Avenue Minneapolis,MN 55412 612.522-601 Breckenridge 11685 Lake Blvd.North Chicago City,MN 55013 612-257-8400 Family Medical Clinic-Fairview Clinics St.Francis Medical Center Clearwater 3809 42nd Ave So Minneapolis,MN 55406612-721-6261 415 Oak St Breckenridge,MN 56520 218-643-3000 St.Cloud Medical Group-Clearwater Monticello Burnsville 615 Nelson Drive Clearwater,MN 55320 612-558-2293 Hart Medical Clinic Fairview Ridges Hospital Cold Spring 200 Sandberg Road Monticello,MN 55362 612-295-4060 201 East Nieollet Blvd.Burnsville,MN 55337 612.8924000 St.Cloud Medical Group-Cold Spring Mora Cambridge 402 N.Red River Ave 02 Cold Spring,MN 56321 612-6854641 Mom Medical Center Cambridge Memorial Hospital Coon Rapids 224 Seventh St Mora,MN S50S L 612.679-1313 725 So.Dellwood Cambridge,MN 55008 612.6894500 Coon Rapids Medical Center Northfield Cannon Falls 9055 Sptvtgbrook Dr.Coon Rapids.MN 55433 612-780-9155 River Valley Clinic,P.A. Cannon Falls Community Hospital Crystal 1400 Jefenon Noddtfield,MN 55057 507-645-2000 1116 Mill St.W.Cannon Falls,MN 55009 307.263-1221 Northwest Family Physicians,P.A. - Osseo Coon Rapids 5502 W.Broadway Crystal,MN 55428 612-537-8475 Osseo Clinic,P.A. Mercy Medical Center Detroit Lakes 226 Central Ave.Osseo,MN 55369 612.425.2117 4050 Coon Rapids Blvd.Coon Rapids,MN 55433 612-421-8888 MeritCare Clinic Detroit Lakes Perham Detroit Lakes 1245 S.Washington Detroit Lakes,MN 56501 218-846-2000 MeritCare Clinic Perham St.Mary's Regional Health Center Duluth 665 3rd Street SW Perham.MN 56573 218-346-4040 1027 Washington Ave.Detroit Laken,MN L 56501218.847-561 i Duluth Clinic Pine City Duluth 400 East 3rd St Dulud,MN 55805 218725-3156 Mom Medical Center-Pine City St.Luke's Hospital Fargo 220 3rd Ave Pau City,MN 55063 612-629-7505 915 East Fast Street Duluth,MN 55805 218-726-5555 MeritCare Medical Group Plymouth Edina 737 Broadway Fargo,ND 58123 701-234-2000 Camden Physicians,Ltd.-Four Seasons Office Fairview Southdale Hospital MertiCare Broadway Health Centre 9750 Rockford Road Plymouth,MN 55442 612-559-3164 6401 France Ave.So.Edina,MN 55435 612-924.5000 736 Broadway Fargo,ND 58123 701-234-2000 Red Wing Fairmont Farmington Interstate Medical Center Fairmont Community Hospital River Valley Clinic,P.�. 2835 S.Service Drive Red Wing,MN 55066 612-3883503 835 Johnson St Fairmont,MN 56031507-2384254 910 Main Street Fammhgtot,MN 55024 612-463-7181 Robbinsdale Fargo Forest Lake Metropolitan Surgical Associates,P..9. MeritCare Hospital Forest Lake Doctors Clinic 3366 Oakdale Ave.No.0506 Robbinadale,MN 55422 612-588.5422 120 Fourth Street No.Fargo,ND 58122 701.234-6000 121 SE 11th Avenue Forest Lake,MN 55025 612.164-7100 Shakopee Forest Lake Fridley Sundance Medical Clinic,Ltd. District Memorial Hospital Fridley Medical Center 323 Naurnkeag St.Shakopee,MN 55379 612-445.6440 246 I l thAve.SE Forest Lake,MN 350223 612-464-3341 7576 Madison St NE Fridley,MN 55432 612.785-4500 Soderville Fridley Fridley Plaza Clinic Crosstown Medical Clinic Unity Medical Center 6341 Unit/emir/Ave.NE Fridley,MN 55432 612-572-5710 17615 Chisholm Street Soderville,MN 55304 6124334-9040 550 Osborne Rd.Fridley,MN 55432 612-421-2222 Glencoe Spooner Grand Rapids Glencoe Medical Clinic,P.A. Northwest Medical Center-Spooner(Duluth CI Itasca Medical Center 525 18th Street East Glencoe.MN 55336 612.864-3116 707 Ash Street Spooner,WI 54801715-635-2151 126 Fast Ave.S.E.Grand Rapids,MN 55744 21 8-326.3401 Hastings St.Cloud Hastings River Valley Clinic,P.A. St.Cloud Medical Group,P A Regina Memorial Hospital 1210 W.Fast St Hastings,MN 55033 612-43&1800 1301 W.St.Genre!St Cloud,MN 56301612.251-8181 Rd Nini er g Hastings,MN 55033 612-437-3121 Hinckley St.Cloud Surgical Associates,Ltd. Hibbing Mom Medical Center-Hinckley 830 West St Germain.Suite 200 St.Cloud,MN 56301 612.251-1860 Mesabi Regional Medical Center 302 Fee Monument Hinckley,MN 55037 612-384.6189 Virginia 750 n 34th St fitting.MN 55746 21 8-2624881 Hudson East Range Clinics,Ltd. Hudson Hudson Physicians,Ltd. 910 N.6th Ave.Virginia,MN 5579221&741.0150 Hudson Memorial Hospital 400 Wisconsin Street Hudson,WI 54016715-386.8880 Waconia 400WisconsatSt Hudson,WI54016715-386.9321 Hutchinson Lakeview Clinic,Ltd. Hutchinson Medical Center,P.A. 424 Hwy.5 Westwaconis,MN 55387 612.442-4461 Preferred WorkCare:All Providers by Specialty 21-Jun-94 29 Hutchinson S Superior Hutchinson Community Hospital Superior Memorial Hospital River Medical Associates-Elk River w 1093 Hwy.15 S.Hutchinson.MN 55330 612.587-2148 3500 Tower Ave.Superior.WI 54880 715.392-8281 290 Mast Street Northwest Elk River,MN 55330 612-241-0373 Litchfield Virginia Ellsworth Meeker County Memorial Hospital Virginia Regional Medical Center Interstate Medical Canter ' .2 Sibley Ave.S.Litchfield,MN 55355 612-693-3242 901 N 9th St Virginia.MN 55792 218-741-3340 230 Cairns Street Ellsworth,WI 54011715.273-5061 We Fails Waconia Fargo St.Gabriel's Hospital Ridgeview Medical Center MeritCare Clinic Southpointe 816 S.E.2nd St.Little Falls.MN 56435 612.632.5441 500 S.Maple St.Waconia.MN 55387 612.442-2191 2400 32nd Avenue So.Fargo,ND 58104 701.2344800 Melrose Wadena MeritCare Medical Group Melrose Hospital Tri-County Hospital 737 Broadway Fargo,ND 58123 701-234-2000 11 N.5th Ave.W.Melrose,MN 56352 612-256-4231 418 N.Jefferson Wadena,MN 56482 218631-3510 Forest Lake Minneapolis Internal Medicine Forest Lake Doctors Clinic Fairview Riverside Medical Center 121 SE 11th Avenue Forest Lake,MN 55025 612.464-7100 Riverside at 25th Ave.So.Minneapolis.MN 55454 6126726000 Alexandria Fridley University of Minnesota Alexandria Clinic,P.A. Fridley Medical Center Harvard St at East River ltd.Minneapolis,MN 55455 612-626-3899 610 Fillmore St,PO Box 1149 Alexandria.MN 56308 612.763-5123 7576 Madison St NE Fridley,MN 55432 612-785-4500 Monticello Anoka Fridley Plaza Clinic Monticello-Big Lake Community Hospital Mork Clinic 6341 Universn5Ave.NE Fridley,MN 55432 612.572-5710 1013 Hart Blvd.Monticello,30155362 612-295-2945 1833 2nd Avenue South Anoka,MN 55303 612-421.3680 Glencoe Moose Lake Aurora Glencoe Medical Clinic,P.A. Mercy Hospital East Range Clinics-Aurora 525 18th Street East Glencoe,MN 55336 612-864-3116 710 Kenwood Ave.Moose Lake,MN 55767 218.485-4481 405 W 3rd Ave Aurora,MN 55705 218-229-3311 Hastings Mora Bemidji River Valley Clinic,P.A. Kanabec Hospital MeritCare Clinic Bemidji 1210 W.First St.Hastings,MN 55033 612.438 4800 300 Clark St Mon.MN 55051 612-679-1212 1233 34th Sheet NW Bemidji,MN 56601218-759.5000 Hutchinson New Prague Blaine Hutchinson Medical Center,P.A. Queen of Peace Blaine Medical Center 3 Century Avenue Hutchinson,MN 55350612-587-2020 301 2nd St N.E.New Prague,MN 56071 612-758-4431 12175 Aberdeen St NE Blaine,MN 55434 612-785-4200 Lester Prairie New Richmond - Brooklyn Center Lester Prairie Medical Clinic Holy Family Hospital Northport Medical Center,Ltd. 28 Hickory Street No.Lester Prairie,MN 55354 612.393-2527 535 Hospital Rd.New Richmond,WI 54017 715-246-2101 5415 Brooklyn Blvd.Brooklyn Center,MN 55429 612-533-8666 Litchfield Northfield Brooklyn Park Litchfield Medical Clinic Northfield Hospital Brooklyn Park Medical Center 6113.Sibley Ave I it ,R.b4,MN 55335 612693-2804 W.1st St Northfield,MN 55057 507-645-6661 5805 74th Ave.North Brooklyn Park,MN 55443 612-512.5700 Mankato .namia Buffalo Mankato Clinic Mille Lacs Health System Buffalo Clinic,P.A. 1230 East Main St Mankato,MN 36002 507.625-1811 200 N.Elm St.Onamia,MN 56359 612.532-3154 1700 Highway 25 N.Buffalo,MN 55313 612.682-1313 Maple Grove Paynesville Buffalo Family&Specialty Care Center,PA. Camden Physicians,Ltd.-Grove Square Office Paynesville Area Health Care System 303 Catlin Buffalo,MN 55313 612-682-5225 13800 83rd Way Maple Grove,MN 55369 612-420.5822 200 First St Paynesville,MN 56362 612-243-3767 Cambridge Minneapolis Perham Professional Medical Assoc(Cambridge Clinic) Airport Medical Clinic Perham Memorial Hospital 626 SW 7th Avenue Cambridge,MN 55008 612.689.1411 7775 26th Averme South Minneapolis,MN 55450 612.726-1771 665 3rd St SW Perham MN 56573 218-346.4500 Cannon Fails Family Medical Clinic-Fairview Clinics Princeton Cannon Family Health Center 3809 42ndAve So Minneapolis,MN 55406 612-7216261 Fairview Northland Re oral Hospital Family Medical Clinic NE-Fairview Clinics p 1 I::west Mill Street Cannon Falls,NW 55009 50;263-3951 704 Fun St Princeton,MN 55371 612-389-1313 Champlin 2849 Johnson St NE Mirnnespolis MN 55418 612-781-6646 Red Wing Champlin Medical Center Monticello St.John's Regional Hospital 11269 Jefferson Hwy. Hart Medical Clinic �} P soy.Cltangn(irt MN 55316 612 427.9620 1401`W.Fourth Red Wing,MN 55066 612-388-6721 Chisago City 200 Sandbar Road Monucelio MN 55362 612.295 4060 River Falls Chisago Health Services Moorhead River Falls Area Hospital 11685 Lake Blvd.North Chicago City,MN 55013 612-251.8400 MeritCare Clinic Moorhead 1629 E.Division SL River Falls,WI 54022 715-425-6155 Cold Spring 1301 8th Street So.Moorhead MN 56560 701-234-3200 Robbinsdale St.Cloud Medical Group-Cold Spring North Branch North Memorial Medical Center 402 N.Red River Ave a2 Cold Spring,MN 56321 612685.8641 Chisago Health Services 3300 Oakdale Ave.North Robbinsdale,MN 3542_2 612-520-5200 Columbia Heights 7th and Oak North Branch MN 55056 612-574-2353 St.Cloud Columbia Park Clinic Northfield St.Cloud Hospital 4000 Central NE Columbia River Valley Clinic,P.A. p� Heights,MN ssazl 6tz-sn-s7ao 1406 6th Ave.N.St.Cloud,XV 56303 612.251.2700 Coon Rapids 1400 Jefferson Northfield MN 55057 507645.2000 St.Croix Falls Coon Rapids Medical Center Red Wing St.Croix Valley Memorial Hospital 9055 Springbrook On Coon Rapids,MN 55433 612-780.9155 Interstate Medical Center 204 Mama St St.Croix Falls,WI 54022 715-483-3261 Detroit Lakes 2835 S.Service DIM.Red Wing,MN 55066 612-3883303 qt.Paul MeritCare Clinic Detroit Lakes Robbinsdale Jnited Hospital Fernandez,Jr.,M.D.,Rafael F. p 1245 S.Washington Detroit Lake,MN 56301 21s-a46.2o00 333 North Smith.Ave.St.Paul,MN 53102 612-220-8000 Duluth 3366 Oakdale Ave N.4204 Robbinsdale.MN 35422 612-588-4657 Stillwater Duluth Clinic Rogers Lakeview Hospital 400 East 3rd St Duluth,MN 55805 218-725-3156 Bass Lake Physicians 919 W.Anderson St Stillwater,MN 55082 612-439.5330 21305 John Millman Dr Roger,MN 33374 612-1282206 Preferred WorkCare: All Providers by Specialty 21-Jun-94 30 .Z • Soderville binsdale Hu M Crosstown Medical Clinic •rthWorks Rehab Htedical Clinic 17615 Chisholm Street Sodetvil*,MN 55304 612434.9040 4080 West Broadway Robbimdale,MN 55422 612-520-5690 14145 North Forest Blvd.Hugo,MN 55038 612426.9216 -- St.Paul St.Cloud Hutchinson St.Paul Medical Clinic,PLC Processus(Mental Health) Hutchinson Medical Center,P.A. 310 N.Smith Ave#460 St Paul,MN 55102 612.224-7505 600 25th Ave.5,4211 St Cloud,MN 56301 612-252-2976 3 Century Avenue Hutchitwn,MN 55350 612.587-2020 Stillwater St.Paul Litchfield r Stillwater Clinic United Hospital Litchfield Medical Clinic 1500 Curve Crest Blvd.Stillwater,MN 55082 612-439-1233 333 North Smith Ave.St Paul,MN 55102 612-220-8000 611 S.Sibley Ave Litchfield,MN 55355 612.693-2804 Virginia United Pain Center Little Falls East Range Clinics,Ltd. 360 Shaman St(Fort Road Med)St Paul,MN 55102 612420-7246 Family Medical Center,P.A. 910 N. 'h Ave.Virginia,MN 55792 218-741-0150 Stillwater 811 SE 2nd Sheet Lithe Falls,MN 56345 612-6324611 Wac-nia Midwest Spine Institute,P.A. Mankato Lakeview Clinic,Ltd. 1940 So.Greeley St.#105 Stillwater.MN 55082 612.430.3800 Mankato Clinic 424 Hwy.5 West Wacotue,MN 55387 612-442-4461 Virginia 1230 East Main St Mankato,MN 56002 507-625-1811 Woodbury Range Mental Health Center Maplewood River Valley Clinic,P.9. 624 South 13th St Virginia,MN 55792 218-749-2881 Neurological Associates of St.Paul,P.A. 8450 City Centre Dnve Woodbury,MN 55125 612-731-9010 Wahpeton 1655 Beam Avenue Maplewood, 2 . MN 55119 612.2..1 9051 Wyoming MeritCare Clinic Wahpeton Milaca • Wyoming Medical Center 3322nd Avenue No.Wahpeton,ND 58075 701.642.7000 Rum River Medical Associates-Milaca 5350 266th St Wyoming,MN 55092 612-462.1515 White Bear Lake 150 loth Sheet NW,Suite B Milaca.MN 56353 612-983.6101 Mental Health Services MinnHealth,P.A. Minneapolis 4786 Banning Avenue White Best Lake,MN 55110 6124264402 Midwestern Neurological 8c Psychiatric Consultan Alexandria Zumbrota 825 Nicollet Mall#650 Minneapolis,MN 55402 612.332-1356 Alexandria Clinic,P.A. Interstate Medical Center-Zumbrota Minneapolis Clinic of Neurology,Ltd. 610 Fllmore St,PO Box 1149 Alexandria,MN 56308 612.763-5123 525 Mill Street Zumbrota,MN 55992 507-732-7314 2545 Chicago Ave.S.4102 Minneapolis,MN 55407 612-863-4070 Bumsville Neurology Monticello Minneapolis Clinic of Neurology,Ltd. River Place Family Physicians 305 E.Nicollet Blvd.Burnsville.MN 55 337 612-435-8516 Alexandria 1107 Hart Blvd.,Suite 210 Monticello,MN 55362 612-295-3200 Coon Rapids Alexandria Clinic,P.A. Mora Coon Rapids Medical Center • 610 Fiitmote St,PO Box 1149 Alexandria,MN 56308 612.763-5123 Mora Medical Center 9055 Springbrook Dr.Coon Rapids,MN 55433 612.780.9155 Blue Earth 224 Seventh St Mon,MN 55051612479-1313 Detroit Lakes Blue Earth Medical Center Paynesville MeritCare Clinic Detroit Lakes 520 South Galbraith Blue Earth,MN 56013 507-526-7371 Paynesville Area Health Care System 1245 S.Washington Detroit Lakes,MN 56501 218446.2000 Buffalo 200 Fit St Paynesville,MN 56362 612-243-3767 Duluth Buffalo Clinic,P.A. Princeton Adult OP Mental Health Services 1700 Highway 25 N.Buffalo,MN 55313 612-682-1313 Rum River Medical Associates-Princeton St Luke's Hospital Duluth,MN 55805 218.726-5555 Burnsville 919 Northland Drive Princeton,MN 55371612-389-3344 Duluth Clinic Minneapolis Clinic of Neurology,Ltd. South St.Paul 400 East 3rd St Duluth.MN 55805 218-725-3156 305 E.Nicollet Blvd.Buauville,:NN 55337 612-4354516 Neurological Associates of St.Paul,P.A. Edina Cannon Falls 710 19th Avenue Nord[South St Paul,MN 55075 612-221-9051 Adult OP Mental Health Services Cannon Falls Community Hospital St.Cloud Fairview Southdale Hospital Edina,MN 55435 612-924-5000 1116 Mill St W.Cannon Falls,MN 55009 507-263-4221 St.Cloud Hospital Ellsworth Chisago City 1406 6th Ave.N.St Crud,MN 56303 612-251-2700 Interstate Medical Center Chisago Health Services St.Louis Park 230 Cairns Sheet Ellsworth,WI 54011715-273-5061 11685 Lake Blvd North Chicago City,MN 55013 612.257.8400 Minneapolis Clinic of Neurology,Ltd. Fargo Coon Rapids 6490 ExcebiorBlvd.W-4l4 St Louis Park,MN 55426 612-922-3317 Adult OP Mental Health Services Minneapolis Clinic of Neurology,Ltd. St.Paul MenitCare Hospital Fargo,ND 58122 701-234-6000 3960 Coon Rapids Blvd#209 Coon Rapids,MN 55433 612.4274320 Krasnow,M.D.,Brian M. MeritCare Medical Group Duluth 280 N.Smith Ave.#415 St Paul,MN 55102 612-224-5848 737 Broadway Fargo,ND 58123 701-234-2000 Duluth Clinic Neurologic Consultants Golden Valley 400 East 3rd St Duluth.MN 55805 218-725-3156 1690 University Ave 4440 St.Paul,MN 55104 612446.4301 Minneapolis Clinic of Neurology,Ltd. Edina Neurological Associates of St Paul,P.A. 4225 Golden Valley Road Golden Valley,MN 534'2'2 6124884661 Minneapolis Clinic of Neurology,Ltd. '�N.Smith Aver=#550 St.Paul,MN 55102 612-221-9051 Hastings 6363 France Ave.S.,Suite 200 Edina,5+0,155435 612-920-7200 Stillwater River Valley Clinic,P.A. Fargo Stillwater Clinic 1210 W.First St Hastings,MN 55033 612-438.1300 MeritCare Clinic Neuroscience 1500 Curve Crest Blvd.Stillwater MN 55082 612-039 1233 Maplewood 700 1st Ave.S.Fargo,ND 58103 701.234-000 Virginia MinnHealth,P.A. MeritCare Medical Group East Range Clinics,Ltd. 2716 Upper Afton Road Maplewood,MN 55119 612.739-4599 737 Broadway Fargo,ND 58123 701-234-2000 910 N.6thAve Virginia.MN 55792 218-741-0150 Minneapolis Golden Valley . Zumbrota Adult OP Mental Health Services Minneapolis Clinic of Neurology,Ltd. Interstate Medical Center-Zumbrota Fairview Riverside Medical Center Minneapolis,MN 35455 612.672.6 4225 Golden Valley Road Golden Valley,MN 55422 612-588-0661 525 Mill Street Zumbrota MN 55992 507-732-7314 Silver Lake Clinic Hudson Neurosurgery 3900 Stinson Blvd.NE Minneapolis,MN 55421 612.7884565 Hudson Physicians,Ltd. Red Wing 400 Wisconsin Street Hudson,WI 54016715-386-8880 Duluth Interstate Medical Center Duluth Clinic 2835 S.Service Drive Red Wing MN 55066 612-3884503 400 East 3rd St Duluth,MN 55805 218-725.3156 Preferred WorkCare:All Providers by Specialty 21-Jun-94 31 J 1 • ira Fprgo Ophthalmology S binsdale MeritCare Medical Group rthwest Eye Clinic.P.A. - 775 Broadway Fargo.ND 58123 701-234.2000 Bemidji 3366 Oakdale Ave.No.0402 Robbbudale,MN 55422 612588-0755 Fridley MeritCare Clinic Bemidji Shakopee Minneapolis Neurological Surgeons,Ltd. tz33 34th Street NW Bemidji,MN 56601 218-759-5000 Eye Physicians&Surgeons,P.A. 7390 University Avenue Fridley,MN 55432 satellite only Bloomington 1226 East 4th Ave.Shakopee,MN 55379 612-445-5760 lankato Eye Physicians&Surgeons,P.A. St.Cloud Mankato Clinic 600 Wert 98th Street Bloomington,MN 55420 612-884-8338 Eye Surgeons&Physicians,P.A. 1230 East Main St Mankato,MN 56002 507-625-1811 Buffalo 109 Denton Park St Cloud,MN 56303 512-253-3637 Plymouth Buffalo Family&Specialty Care Center,P.9. Northway Eye Associates Minneapolis Neurological Surgeons,Ltd. 303 Catlin Buffalo,MN 55313 612.682-5225 1543 Northway Drive St.Cloud..MN 56303 612-253-2441 505 Noah Hwy 169,Suite 230 Plymouth,MN 55441 612-5447562 Burnsville St.Louis Park St.Paul Eye Physicians&Surgeons,P.4. Northwest Eye Clinic,P.A. Neurosurgery Associates.Ltd. 14050 Nicollet Ave.So.Burnsville,MN 55337 612-435-4170 6490 Excebiot Blvd.Suite W301 St Louis Park,MN 55426 612-926.2 280 N.Smith 0234 St Paul,MN 55102 612-227-7088 Cambridge St.Paul Occupational Medicine Professional Medical Assoc(Cambridge Clinic) Associated Eye Physicians&Surgeons,Ltd. 626 SW 7th Avenue Cambridge,MN 55008 612-689.1411 280 No.Smith Ave.Suite 840 St Paul,MN 55102 612-222-5666 Bloomington Champlin Stillwater HealthWorks Champlin Medical Center Associated Eye Physicians&Surgeons,Ltd. 600 West 98th St.Suite 395 Bloomington,MN 55420 612-885.6170 11269 Jefferson Hwy.Champlin,MN 55316 612-427-9620 232 No.Main Street Stillwater,MN 55082 612-439-8500 Brooklyn Park Chisago City Virginia Brooklyn Park.Medical Center Chisago Health Services East Range Clinics,Ltd. 5805 74th Ave.North Brooklyn Park,MN 55443 612-572-5700 11685 Lake Blvd.North Chisago City,MN 55013 612-257-8400 910 N.6th Ave.Virginit MN 55742 218-741-0150 Cambridge Coon Rapids Waconia Occupational Medicine-Cambridge Hospital Coon Rapids Medical Center Eye Physicians&Surgeons.P.A. 725 South Dellwood Cambridge,MN 55008 612-689-7777 9055 Springbrook Dr.Coon Rapids,MN 55433 612-780.9155 550 So.Maple Waconia,MN 55387 612-442-4445 Columbia Heights Duluth Lakeview Clinic,Ltd. Columbia Park Clinic Duluth Clinic 424 Hwy.5 West Waconia,MN 55387 612-142-4461 4000 Central Avenue NE Columbia Heights,MN 55421612-572-5700 400 East 3rd St Duluth,MN 55805 218-725-3156 Wayzata Coon Rapids - Edina Northwest Eye Clinic,P.A. Coon Rapids Medical Center Eye Physicians&Surgeons,P.A. 250 Na.CmtralAve�Suite 107 Wayzata.MN 55391 612-173-4216 9055 Sptatgbrook Dr.Coon Rapids,MN 53433 612-780-9155 4450 West 76th Street Edina,MN 55435 612-831-8811 Oral/Dental Surgery Duluth Fargo 1 Duluth Clinic MeritCare Medical Group Fargo 3 East 3rd St Duluth,MN 55805 218-725-3156 737 Broadway Fargo,ND 58123 701-2342000 MetitCare Medical Group Cagan Forest Lake 737 Broadway Fargo,ND 58123 701-234-2000 United Occupational Health Associated Eye Physicians&Surgeons,Ltd. Hutchinson 990 Lone Oak Road,Suite 120 Eagan,MN 55121 612-452-8266 828 So.Lake Street Forest Lake,MN 55025 612-4644000 Wang,DDS,P.A.,Joseph H. Edina Fridley 45 East Library Square Hutchinson,MN 55350 612.587-4644 Occupational Medicine Consultants Fridley Medical Center Willmar 6500 Bathe Road,Suite 10 Edina,MN 55435 612-920-5663 7576 Madison St NE Fridley,MN 55432 612785-4500 Wang,DDS,P.A.,Joseph H. Fridley Fridley Plaza Clinic 1101 First St South Willmar,MN 56201 6122-235.7290 Fridley Plaza C1171ic 6341 University Ave.NE Fridley,MN 55432 612-5724710 Orthopedics 6341 University Ave.NE Fridley,MN 55432 612572-5710 Golden Valley Mankato Medical Vision Center Aitkin Mankato Clinic 5657 Duluth Street Golden Valley,MN 55422 612.542-1176 Orthopaedic Associates of Duluth,P.A. 1230 East Main St Mankato,MM 56002 507.6254811 Hastings Ripple River Clinic Aitkin.MN 56431 218-927-2157 Minneapolis River Valley Clinic,P.A. Albany Airport Medical Clinic 1210 W.Fret St Hastings,MN 55033 6124384800 Little Falls Orthopedics , 7775 26thAvenne South Minneapolis,MN 55450 612-726-1771 Mankato 320 3rd Avenue Albany,MN 56307 612-845-2157 HealthWorks Mankato Clinic Anoka 3033 University Ave.SE Minneapolis,MN 55414 612-379-1244 1230 East Main St Mankato,MN 56002 507-6254811 Mork Clinic Occupational Health Group Minneapolis 1833 2nd Avenue SoutliAnoka,MN 55303 612-421-3680 825 S.8th Street,Suite 1208 Minneapolis,MN 55404 612.336-7119 Medical Vision Center Bemidji Red Wing 4001 Stinson Blvd.NE 4224 Minneapolis,MN 55421 612-7 81.6911 MeritCare Clinic Bemidji Interstate Medical Center Northfield 1233 34th Street NW Bemidji.MN 56601 218.759-5000 2835 3.Service Drive Red Wing,MN 55066 612-388-3503 Linde,MD,Ronald Bloomington Roseville 500 South Water St Northfield,MN 55057 507-645.6619 Orthopedic Surgeons,Ltd. Physicians Neck&Back Clinic River Valley Clinic,PA 600 W.98th Street#I50 Bloomington,MN 55420 612-927-4525 3050 Centre Pointe Drive,4200 Roseville,MN 55113 612.639.9150 1400 Jefferson Northfield,MN 55057 507.645-2000 Blue Earth Rosedale Medical Center Princeton Blue Earth Medical Center 2393 Fairview Ave.N.Roseville,MN 55113 612-785-4300 Rum River Medical Associates-Princeton 520 South Galbraith Blue Earth,MN 56013 507-526-7371 St.Cloud 919 Northland Drive Princeton,MN 55371 612-389-3344 Brooklyn Center Midwest Occupational Medicine Red Wing Midwest Spine Institute,P.A. 1545 Northway Drive St Cloud,MN 56303 612-251-9675 Interstate Medical Center 3300 County Rd.10,Suite 520 Brooklyn Center.MN 55429 612-566-50 St.Paul 2835 S.Service Drive Red Wing,MN 55066 612-388-3503 Brooklyn Park United Occupational Health Brooklyn Park.Medical Center 280 N.Smith Avenue,Suite 144 St Paul,MN 55102 6122204106 5805 74th Ave.North Brooklyn Park,MN 55443 612-572-5700 Preferred WorkCare: All Providers by Specialty 21-Jun-94 32 r 1 el • Buffalo Lake PI Buffalo Clinic,P.A Lake Doctors Clinic C tic Consultants,P.0-, . 1700 Highway 25 N.Buffalo,MN 55313 612-682-1313 121 SE 11th Avenue Forest Lake,MN 55025 612-464-7100 12805 Highway 55,Suits 111 Plymouth,MN 55441 612-176-0042 Buffalo Family&Specialty Care Center,P.A. Fridley Princeton 303 Catlin Butlino,MN 55313 612-682-5225 Fridley Medical Center Northwestern Orthopaedic Surgeons P.A. Burnsville 7576 Madison St NE Fridley,MN 55432 612-785-4500 400 Second Street So.,Suite 120 Princeton,MN 55371 612-389.9281 ' Orthopaedic Consultants,P.A. Fridley Plaza Clinic Orthopaedic Consultants,P.A. 14050 Nicollet Ave.So.0210 Burnsville,MN 55337 612-892-5977 6341 Univeaity Ave.NE Fridley,MN 55432 612-572-5710 919 Northland Drive Princeton MN 55371 612-389-6675 305 East Nicoilet Blvd.Burnsville,MN 55337 612-8924800 Northwestern Orthopaedic Surgeons Rum River Medical Associates-Princeton Cambridge 8290 University Ave.NE#200 Fridley,MN 55432 612-786-9543 919 Northland Drive Princeton,MN 55371 612-389-3344 North Suburban Orthopaedics&Sports Medicine Glencoe Red Wing 626 SW 7th Avenue Cambridge,MN 55008 612-434-6622 Orthopaedic Consultants,PA Interstate Medical Center Professional Medical Assoc(Cambridge Clinic) 701 East 18th St.Glencoe,MN 55336 612.864-3121 2835 S.Service Drive Red Wing,MN 55066 612-388-3503 626 SW 7th Avenue Cambridge,MN 55008612.689-1411 Hastings Robbinsdale Chanhassen Landmark Orthopedics,Ltd. Northwest Bone&Joint Associates,P.A. Orthopaedic Consultants,P.A. 1285 Nininger Road.Suite 203 Hastings,MN 55003 612-641-0673 3366 Oakdale Avenue Nonh#103 Robbinsdale,MN 55422 612-520-78 470 West 78th Street Chanhassen,MN 55317 612-934-0570 River Valley Clinic,P.A. 3366 Oakdale Avenue North#203 Roobinsdale,MN 55422 612-520.78 Chisago City 1210 W.Fast St Hastings,MN 55033 612-438-1800 Roseville Chisago Health Services Hudson Physicians Neck&Back Clinic 1 1685 Lake Blvd.North Chicago City,MN 55013 612-257-8400 Hudson Physicians,Ltd. 3050 Centre Pointe Drive,#200 Rtxcnile,MN 551 13 612639A150 Cloquet 400 Wisconsin Street Hudson,WI 54016715-386.8880 Rosedale Medical Canter Orthopaedic Associates of Duluth,P.A. Lakeville 2393 Fairview Ave.N.Roseville,MN 55113 612-785-4300 417 Skylind Blvd.Cloquet,MN 55720 218.879.1271 Orthopaedic Consultants,P.A- Savage Columbia Heights 17599 Kenwood Trail Lakeville,MN 55044 612-892-5801 Orthopaedic Consultants,P.A. Columbia Park Clinic Little Falls 4011 West Highway 13 Savage,MN 55378 612.890.8736 4000 CentralAvenue NE Columbia Heights,MN 55421 612-572-5700 Little Falls Orthopedics,P.A. Shoreview Coon Rapids 808 3rd Street SE Little Falls,MN 56345 612-632-3671 Northwestern Orthopaedic Surgeons Coon Rapids Medical Center Long Prairie 4625 Churchill Street,Suite 200 Shoreview,MN 55126 612-481-1071 9055 Springbrook Dr.Coon Rapids,MN 55433 612-780-9155 Little Falls Orthopedics,P.A. Soderville North Suburban Orthopaedics&Sports Medicine Long Prairie Clime Long Prairie,MN 56347 612-732-2131 Crosstown Medical Clinic 3960 Coon Rapids Blvd.,Ste.315 Coon Rapids,MN 55433 612-427-4 Mankato 17615 Chisholm Street Soderville,MN 55304 612.434-9040 Detroit Lakes Orthopedic and Fracture Clinic St.Cloud MeritCare Clinic Detroit Lakes 309 Holly Lane,Box 3487 Mankato,MN 56002 507.3886265 St.Cloud Orthopedic Assn.,Ltd. 1245 S.Washington Detroit Lakes,MN 56501218.846-2000 Maplewood 1555 Northway Drive St Cloud,MN 56303 612-259-4100 Duluth Summit Orthopedic Associates,P.A. St,Paul Duluth Clinic 1560 Beam Avenue,Suite D Maplewood,MN 55109 612-770-5773 Landmark Orthopedics,Ltd. 400 East 3rd St Duluth,MN 55805 218-725-3156 Milaca 1690 University Avenue 0180 St Paul,MN 55104 612-645-8980 Orthopaedic Associates of Duluth,P.A. Orthopaedic Consultants,P.a. 17 West Exchange St 8307 St Paul,MN 55102 612-227-0200 1000 East Fast St,Suite 402 Duluth,MN 55805 218-722-5513 15010thAverme NW Mika,MN 56353 612-9836101 Orthopaedic Consultants,P.A. Eagan Minneapolis 1690 University Ave,Suite 410 St.Paul,MN 55104 612-232-4770 Orthopaedic Consultants,P.A. Metropolitan Spine Group Summit Orthopedic Associates,P.A. 1440 Oucicwood Drive Eagan MN 55122 612.688-7856 606 24th Ave So#701 Minneapolis,MN 55454 612.341.9220 293 West Seventh St Suits 100 SL Paul MN SS 102 612.297 6909 Eden Prairie Minneapolis Sports Medicine Center Stillwater Orthopedic Surgeons,Ltd. 70125thAve.So.,Suite 400 Minneapolis,NW 55454 612-339-7734 Midwest Spine Institute,P.�. 830 Prime Center Dr.5140 Eden Prairie,MN 55344 612-944-9606 Orthopaedic Consultants,P.A 1940 So.Greeley St#105 Stillwater MN 55082 612-430 3800 Edina 825 So.8th Street,Suite 504 Minneapolis,MN 55404 612-337-0415 St.Croix Orthopedics,P.A. Orthopaedic Consultants,P.A on6 24M,Ave.So.,Suit 300 Minneapolis.MN 55454 612-672.4131 1701 et'-"re C-nat Blvd-Sh-lWata.`-_^;55C82 512.439.8807 7201 Washington Ave.So 4100 Edina,MN 55439 612-9442519 74 So.9th Street Suits 711 Minneapolis,MN 55402 612.3326757 Superior Orthopaedic Consultants,P.A. 606 24th Ave.So.,Suite 119 Minneapolis,MN 55454 612-3394376 Orthopaedic Associates of Duluth,P.A. 7373 France Ave.So Suit 312 Edina MN 55435 612 832-0016 701 25th Ave.So.,Suite 402 Minneapolis,MN 55454 612-339-8976 N.28th&HM Avenue St4pet' WI 54880 715-392-8370 Orthopaedic Consultants,PA Monticello Two Harbors 6363 ranee Ave.So.Suite 500 Edina,MN 55435 612-925-2535 Hart Medical Clinic Orthopaedic Associates of Duluth,P.4. 200 Sandberg Road Monticello,MN 55362 612.295-4060 Orthopedic Surgeons,Ltd. 11th Avenue et4thTwoHarbors MN 55616 218-834-7210 6363 France Ave.S.#404 Edina,MN 55435 612-927-4525 North Suburban Orthopaedics&Sports Medicine Virginia Southdale Orthopedics,P.� 10t3 Hart Blvd.Monticello,MN 55362 612 cello, -ss1-0301 East Range Clinics,Ltd. 6545 Frans Avenue S.,4404 Edina,MN 55435 612-920.6322 Moose Lake 910 N.6th Ave.Virginia,MN 55792 218-741-0150 Elk River Orthopaedic Associates of Duluth,P.�.. Waconia North Suburban Orthopaedics&Sports Medicine Gateway Clinic Moose Lake MN 35761218389 6150 Lakeview Clinic,Ltd. 501 Main Street,Suite 102 Elk River,MN 55330 612-441-0301 Northfield 424 Hwy.5 West Waconia,MN 55387 612-442-4461 Orthopaedic Consultants,P.A. Orthopedic and Fracture Clinic Orthopaedic Consultants,PA 290 Main Street Elk River.MN 55330 612-441-0298 1381 Jefferson Road Northfield,MN 55057 507 643-7352 501 So.Maple Waeonia,MN 55387 612-442-2163 Fargo River Valley Clinic,P.A. Wayzata MeritCare Medical Group 1400 Jetiaaon Northfield MN ssO515o7645-2000 Orthopaedic Consultants,PA 737 Broadway Fargo,ND 58123 701-234-2000 Owatonna 250 Cabral Ave No.,Suite 303 Way eta MN 55391 612 4164042 MertiCare Broadway Health Centre Orthopedic and Fracture Clinic Orthopedic Surgeons,Ltd. i 736 Broadway Fargo,ND 58123 701-234-2000 134 Southvtrw,Suit 201 Owatonna MN 55060 507-431 8866 250 N.Cenral Ave.#205 Wa Faribault Perham Woodbury 3�55391 612 449 9192 Orthopedic and Fracture Clinic MeritCare Clinic Perham Landmark Orthopedics,Ltd. 633 SE 1st Street Fanbeuit MN 55021 50 7-3344601 665 3rd Street SW Perham,MN 56573 2183464040 2056 Woodbine Drive Woodbury,MN 55125 612435-9502 Preferred WorkCare: All Providers by Specialty 21-Jun-94 33 r 1 Ski $t Croix Orthopedics,P.A. Hutchinson :025 Woodlane Drive.Suite 200 Woodbury,MN 55125 612-73 Hutchinson Medical Center.P.A. //radii tCare Clinic Bemidji ' Ili Zumbrota 3 CentiayAvenue Hutchinson.MN 55350 612-587-2020 1233 34th Street NW Bemidji,MN 56601 218.759.5000 Interstate Medical Center-Zumbrota Mankato Bloomington 525 Mill Street Zumbrota,MN 55992 507-732.7314 Mankato Clinic Institute for Athletic Medicine `)rthopedics: Hand Surgery 1230 East Main St Mankato,MN 56002 507.625-1811 600 West 98th Street#100 Bloomington,MN 55420 612-885.6200 Monticello Brooklyn Center Coon Rapids Hart Medical Clinic Midwest Physical Therapy Landmark Orthopedics,Ltd. 200 Sandberg Road Monticello,MN 55362 612.2954060 3300 County Road 10#520 Brooklyn Center,MN 55429 612-560.6177 3960 NW Coon Rapids Blvd#104 Coon Rapids,MN 55433 612-641-06Northfield Brooklyn Park Edina River Valley Clinic,P.A. Anoka Physical Therapy Orthopaedic Consultants,P.A. 1400 Jefferson Northfield,MN 55057 507-645-2000 6800 78th Ave North Brooklyn Park,MN 55433 612-560.3553 7373 France Ave.So,Suite 312 Edina,MN 55433 612-832.0076 Princeton Institute for Athletic Medicine Hastings Rum River Medical Associates-Princeton 8559 Edinbrook Pkwy M106 Brooklyn Park,MN 55443 612-493-5668 Landmark Orthopedics,Ltd. 919 Northland Drive Princeton,MN 55371 612-389-3344 Buffalo 1285 Nininger Road,Suite 203 Hastings,MN 55003 612-641-0673 St.Paul Excel Physical Therapy River Valley Clinic,P.A. Head&Neck Physicians&Surgery Clinic 108 Marry Drive Buffalo,MN 55313 612-682-2439 1210 W.Fun St Hastings,MN 55033 612.4384800 310 N.Smith#1 20 St.Paul,MN 55102 612-227-0821 Burnsville Maplewood Virginia Fairview Ridges Physical Therapy Landmark Orthopedics,Ltd. East Range Clinics,Ltd. 201 East Nicollet Blvd.Burnsville,MN 55337 612-892-2121 1655 Beam Ave.,Suite 130 Maplewood,MN 55109612641.0673 910 N.6th Ave.Virginia,MN 55792218-741-0150 Institute for Athletic Medicine Minneapolis 305 East Nicollet Blvd.#292 Burnsville,MN 55337 612-892-2650 Landmark Orthopedics,Ltd. Pain Programs 305 7775 26th Ave.So.,Suite 130 Minneapolis,MN 55450 612.641.0673 Edina Rum River Therapy Center-Cambridge Orthopaedic Consultants,P.A. Pain Management Center(Southdale) 725 So.Bellwood Cambridge,MN 55008 612.689-7782 701 25th Ave.So,Suite 402 Minneapolis,MN 55454 612-339-8976 6543 France Ave S0.Suite 270 Edina,MN 55435 612-924-5542 Clearbrook St.Paul Golden Valley MeritCare Clinic Clearbrook Landmark Orthopedics,Ltd. Minneapolis Clinic of Neurology Pain Program Elm Street Clearbrook,MN 56634 218.776-3124 393 N.Dunlap,Suite 850 St.Paul,MN 55104 612-641-0673 4225 Golden Valley Road Golden Valley,MN 55422 612-588-0661 Cold Spring Metropolitan Hand Surgery Assoc. _ Minneapolis Great River Physical Therapy 310 N.Smith Ave.,Suite 370 St Paul,MN 55102 612-291-8773 402 Red River Avenue No.Cold Spring,MN 56320 612.685-7155 Pain Rehabilitation Ctr.(Riverside) Woodbury 2450 Riverside Avenue Minneapolis,MN 55454 612-672-2835 Coon Rapids Landmark Orthopedics,Ltd. - Robbirisdale Coon Rapids Medical Center 2056 Wood's=-.nve Woodbury,MN 55125 612.735-9502 9055 Springbrook Dr.Coon North Pain Institute ptingbr Rapids,MN 55433 612.780 9153 `tolaryngolog 4080 West Broadway,Suite 310 Robbinadale,MN 55422 612-520-7246 Team Work Industrial Rehabilitation St.Paul 8960 Sprargbrook Drive,Ste 140 Coon Rapids,MN 55433 612-785-796 Brooklyn Park United Pain Center Two Rivers Center,Inc. Brooklyn Park Medical Center 360 Sherman St(Fort Road Mad)St Paul,MN 55102 612-220-7246 3505 Northdale Blvd.NW Coon Rapids,MN 55448 612.427.0032 5805 74thAve.North Brooklyn Pads,MN 55443 612-572-5700 Cottage Grove Buffalo Physiatry Family Physical Therapy of Cottage Grove 7500 80ttt Street S.0101 Cottage Grove,MN 55016 612.459-9686 Buffalo Clinic.P.A. Duluth Crystal 1700 Highway 25 N.Buffalo,MN 55313 612682-1313 ry Duluth Clinic Institute for Athletic Medicine Buffalo Family&Specialty Care Center,P.A. 400 East 3rd St Duluth,MN 55805 218-725-3156 303 Catlin Buffalo,MN 55313 612.682-5225 5510 West Broadway#205 Cryatel,MN 35428 612.537.1208 Edina Coon Rapids Detroit Lakes Spine Care Center(FV-Southdale) Coon Rapids Medical Center MeritCate Clinic Detroit Lakes 6545 Franca Ave So,Suite 280 Edina,MN 55435 612-924-5048 1245 S.Washington Detroit Lakes,MN 56501 218.846.2000 9055 Springbrook Dt Coon Rapids,MN 55433 612-780-9155 Fargo Duluth Duluih Clinic MeritCare Medical Group Duluth t Luke's Hospital PT 400 737 Broadway Fargo,ND 58123 01.234-2000 915 East Fast Street Duluth,MN 55805 218-726-5373 . 3rd St Duluth,MN 55805 218-725-3156 St.Cloud Fargo Eagan St.Cloud Medical Group,P.A. Institute for Athletic Medicine bleritCare Medical Group 1301 W.St Germain St Cloud,MN 56301 612-251-8181 737 Broadway Fargo,ND 58123 701-234-2000 1440 Duckwood Drive Eagan,MN 55 122 612-688-7857 St.Paul Spectrum Therapy Centers Forest Lake P mPY United Hospital Physical Therapy 990 Lana Oak Road,Suite 118 Eagan,MN 55121612686.0098 Forest Lake Doctors Clinic 333 North SmithAvenue St Paul,MN 55102 612-2220 4290 121 SE l IthAvenue Forest Lake,MN 55025 612.464-7100 Eden Prairie Stillwater Institute for Athletic Medicine Fridley Midwest Spine Institute,P.A.Fridley Plaza Clinic Q 830 Prairie Center Dr.#170 Eden Praise,MN 53344 612.946-1131 1940 So.Greeley St 5105 Stillwater,MN 55082 612430.3800 Edina 6341 University Ave.NE Fridley,MN 55432 612-572-5710 Hastings Physical Therapy Fairview Southdale Physical Therapy 6401 Frew Avenue South Edon.MN 55435 612.924-5060 River Valley Clinic,P.A. Alexandria Industrial Medicine&Hand Therapy 1210 W.First St Hastings,MN 55033 612—t38-1800 Hudson Douglas County Hospital 6545 France Ave So##401 Edina,MN 35435 612-925-1609 iudson Physicians,Ltd. 111 17th Avenue East Alexandria,MN 56308 612-762-6079 Institute for Athletic Medicine 400 Wisconsin Street Hudson WI 34016 715-386 8880 Anoka 7201 WashingtonAverme So.Edina,MN 55439 612-944-5314 Hugo Anoka Physical Therapy 7110 Franca Avenue South Edina.MN 55435 612.920-8525 Hugo Medical Clinic 403 Jackson St Anoka,MN 55303 612-427-0862 Saunders Therapy Centers 6550 York Avenue South Edina,MN 55435 612-924-0199 14145 North Forest Blvd.Hugo,MN 55038 612.426-9226 Preferred WorkCare: All Providers by Specialty 21-Jun-94 34 r r A Elk River Orville 8960 k Dave,Ste 140 CoonRapida,MN 55433 612-785-796 61 _ Two Rivers Center.Inc. ily Physical Therapy of Roseville T ers Center,Inc.(FCE/WH) ` III 530 3rd Street Elk River,MN 55330 612441-8l 11 1935 ay.Rd.32.Suite 140 R0,44,014.MN 55113 612.636-2666 3505 NottMat Blvd.NW Coon Rapids,344 55448 612427-0032 '4 Fargo MultiCenter Therapy Duluth MeritCare Hospital 2393 North Fairview Ave Roseville,MN 55113 612-636-8650 St.Luke's Physical Therapy(WH/FCE) 720 Fourth Street No.Fargo,ND 58122 701-234-6000 Physicians Neck&Back Clinic 915 East Fast Street Duluth,MN 55805 218-726-5373 MeritCare Medical Group 3050 Cann Pointe Drive,0200 Roseville,MN 55113 612.639.9150 Eagan 737 Broadway Fargo.ND 58123 701-234.2000 Savage Spectrum Therapy Center(FCE/WH) MertiCare Broadway Health Centre Institute for Athletic Medicine 990 Lone Oak Road,Swte 118 Eagan,MN 55121 612-686-0098 736 Broadway Fargo,ND 58123 701-234-2000 4011 W.Highway 13 Savage,MN 55378 612-882-0758 Edina Forest Lake Shoreview Industrial Medicine&Hand Therapy Orthopaedic Sports,Inc. Northern PT&Athletic Medicine 6545 Franca Ave So 0 0401 Edina,MN 55435 612-925-1609 146 North Lake Street Forest Lake,MN 55025 612.646.8502 4625 Churchill Street,Suite 200 Shoreview,MN 55126 612-481-1071 Saunders Therapy Centers(WH/FCE) Fridley Soderville 6550 York Avenue South Edina,MN 55435 612-924-0199 Northern PT&Athletic Medicine Rum River Therapy Center-Crosstown Fridley 8290 University Ave.NE#200 Fridley,MN 55432 612.786.2340 17615 Chisholm Street Soderville,MN 55304 512-334-9040 Industrial Medicine&Hand Therapy Hastings Spring Lake Park 8290 University Ave 0 100 Fridley.MN 55432 612.784-0436 Family Physical Therapy of Hastings MultiCenter Therapy Hastings 1285 Nininger Road,Suite 107 Hastings,MN 55033 612-438.3920 7700 Highway 65 NE Spring Lake)Park.MN 55432 612-784-3155 Family Physical Therapy of Hastings Hibbing St.Cloud 1285 Nininger Road,Suite 107 Hastings,MN 55033 612438-3920 Mesabi Regional Medical Center Great River Physical Therapy Mankato 750 E.34th St.Hibbing,MN 55746 218.262-4881 127.5 West St Germain St St Cloud,MN 56301 612-251.2730 OFC Back Care Center(WH/FCE) Mankato Northern Star Therapy,Ltd 309 Holly Lane Mankato,MN 56001 507-345-6299 Immanuel St.Joseph's Physical Therapy 1411 West St Germain St.Cloud,MN 56301 612-259-5429 Minneapolis 1025 Marsh Sty PO Box 8673 Mankato,MN 56002 507-345-2669 St.Cloud Orthopedic Assoc.Physical Therapy Minnesota Lumbar Spine Clinic(WH/FCE) OFC Back Care Center 1555 Northway Drive St Cloud,MN 56303 612.2594100 825 3.8th Street,Suite 510 Minneapolis,MN 55404 612-338-0566 309 Holly Lane Mankato,MN 56001 507-345-6299 St.Paul 606 24th Avenue Sow Suite 708 Minneapolis,MN 55454 612-341.9218 Physical Therapy Sports Medicine Center Family Physical Therapy&Sports Rehab Riverside Work-Up Program 309 Holly Lane Mankato,3N 56001 507-387-3444 411 North Lexington Pkwy.St.Paul,MN 55104 612.644-842-2 2450 Riverside Avenue Minneapolis,MN 55454 612.672.6705 Wenger Physical Therapy Saunders Therapy Centers North Mankato 310 Belle Avenue Mankato,MN 56001 507-625-8010 2334 University Av W,Suite 170 St Paul,MN 55114 612.645-8083 Wenger Physical Therapy(WH/FCE) Maplewood Spectrum Therapy Center 1681 Commerce Drive North Mankato,MN 56003 507-625-8017 Family Physical Therapy Associates 360 Sherman Street,Suits 300 St Paul,MN 55102 612.291-0266 Red Wing 1812 North St Paul Road Maplewood,MN55109612.779.8550 United Hospital Physical Therapy River City Rehab(WH/FCE) Orthopaedic Sports,Inc. 333 North Smith Avenue St Paul,MN 55102 612-2204290 133 Media Avenue Red Wing,MN 55066 612-388-5011 1655 Beam Ave.,Suite 308 Maplewood,MN 55109612-779-6543 Stillwater Robbinsdale , Minneapolis Midwest Physical Therapy Industrial Medicine&Hand Therapy Institute for Athletic Medicine 1940 So.Greeley St#120 Stillwater,MN 55082 612.430.9319 3366 Oakdale Ave No 4141 Robbinsdale,MN 55422 612-521-3256 701 25th Ave So 4500 Minneapolis,Net 55454 612.672.6697 Orthopaedic Sports,Inc. NorthWorks Rehab(WH/FCE) Minnesota Lumbar Spine Clinic 1700 Tower Drive West Stillwater,MN 55082 612-439.8540 4080 West Broadway Robbinsdale,MN 55422 612-520-5690 60624th Avenue So.,Suite 708 Minneapolis,MN55454612-341-9218 Superior Spring Lake Park 825 S.8th Street,Suite 510 Minneapolis,MN 55404 612-338.0566 Center For Muscle&Joint Therapy MultiCenter Therapy(WH/FCE) Riverside Spine&Orthopedic PT 1420 Oakes Avenue Superior,WI54880715-394-6355 7700 Highway 65 NE Spring Lake Park,MN 55432 612-784-3155 606 24th Ave So,Suite 301 Minneapolis,MN 55454 612-672-4940 Virginia St.Paul Minnetonka Iron Range Rehabilitation Center Saunders Therapy Centers(WH/FCE) Institute for Athletic Medicine 1001 N.9th Ave Virginia,MN 55792 218-7494405 2334 University Av W,State 170 St Paul,MN 55114 612.645-8083 2000 Plymouth Road 4365 Minnetonka,MN 55305 612-525-1883 W.St.Paul Spectrum Therapy Center(FCE/W13) Mora Family Physical Therapy of West St.Paul 360 Shaman Street,Suite 300 St Paul,MN 55102 612-291-0266 KarlabecHospital 60 East Made Ave,Suite 105W.St Paul,MN55118 612-451-6156 Stillwater 300 Clark St Mora,MN 55051612.679-1212 White Bear Lake Midwest Physical Therapy North Mankato Family Physical Therapy of White Bear Lake 1940 So.Greeley St#120 Stillwater,MN 55082 612.430.9319 Wenger Physical Therapy 1310 East Hwy.96,Suite 209 White Bear Lake,54Q 55110 612-426-77 Orthopaedic Sports,Inc.(The Work Center) 1681 Commerce Drive North Mankato,MN 56003 507.6254017 Woodbury 1410 Frontage Road West Stillwater,MN 55082 612439-9509 Osseo Family Physical Therapy of Woodbury Virginia Institute for Athletic Medicine 2056 Woodlane Drive Woodbury,MN 55125 612-731-2286 Iron Range Rehabilitation Center 100 Central Averme North Osseo,MN 55369 612-424-0534 Orthopaedic Sports,Inc. 1001 N.9th Ave Virginia,MN 55792218-749-9405 Owatonna 2025 Woodlane Dr.,Suite 100 Woodbury,MN 55125 612-7384270 White Bear Lake Owatonna Physical Therapy Physical Therapy-FCE/ Family Physical Therapy of White Bear Lake 1414 So Oak Owatonna,MN 55060 507-451-8254 1310 East Hwy.96,Suite 209 White Bar Lake,MN 55110 612426-77 Plymouth WH Physical Therapy:Hand Institute for Athletic Medicine 9750 Rockford Road Plymouth,3,1l4 55442 612-557-9000 Alexandria Therapy 1495 Highway 101 North Plymouth,MN 55447 612-476.6782 Douglas County Hospital(Return-To-Work) Red Wing 111 17thAveme East Alexandria,MN 56308 612;62.6103 Burnsville River City Rehab Cambridge Fairview Hand Center(Ridges) 133 HedinAvenue Red Wing,MN 55066 612-388-5011 Rum River Therapy Center(WH/FCE) 201 East Nicollet Blvd Burnsville,4N 55337 612-892-2121 L Robbinsdale 725 So.Dcllwood Cambridge,MN 55008 612-689-7782 Edina Institute for Athletic Medicine Coon Rapids Fairview Hand Center(Southdale) 4080 West Broadway 0300 Robbinsdale,MN 55422 612-533 4541 TeamWork Industrial Rehabilitation 6545 France Ave So,Suite 366 Edina,MN 55435 612-924-1520 Preferred WorkCare: All Providers by Specialty 21-Jun-94 35 • lost -• Industrial Medicine&Hand Therapy St.Peter an At 6545 France Ave So#$401 Edina.MN 55435 612-925-1609 Nichols,DPM,William N. eat Care-Eagan "ridley 618 West Broadway St Peter,MN 56082 501-931-3328 990 Lone Oak Road Eagan.MN 55121 612-454-7809 Industrial Medicine&Hand Therapy Waconia Edina 8290 University Ave#100 Fndley,MN 55432 612-784-0436 Lakeview Clinic,Ltd. Urgent Care-Fairview Southdale Minneapolis 424 Hwy.5 West Waconia,MN 55387 612-142-4461 6401 France Ave So Edina,MN 55435 612-924-5030 Fairview Hand Canter(Riverside) Wahpeton Maple Grove 006 24th Ave So.,Suite 301 Minneapolis,MN 55454 612.171-6996 MeritCare Clinic Wahpeton Urgent Care-Grove Square Convenience Care Robbinsdale 332 2nd Avenue No.Wahpeton,ND 58075 701-642-7000 13800 83rd Way Maple Grove,MN 55369 612.420-5279 Industrial Medicine and Hand Therapy White Bear Lake Minneapolis 3366 Oakdale Ave No 4141 Robbinsdale,MN 55422 612.521-3256 MinnHealth,P.A. Urgent Care-Family Medical Clinic St.Paul 3220 Bellaire Avenue White Bear Lake,MN 55110 612.777.5235 2849 NE Johroon St Minnapolia,MN 55418 612-781-9436 Minnesota Hand Rehabilitation 4786 Banning Avernus White Bear Lake,MN 55110 612-4266402 Urgent Care-Riverside Medical Ctr 393 N.Dunlap St,Suite 310 St Paul,MN 55104 612-646.4263 Radiology Riverside at 24th Ave Minneapolis,MN 55454 612672-6771 Plastic Surgery Plymouth Bemidji Urgent Care-Plymouth Convenience Care Burnsville Northern Radiology Consultants 3900 Vmewood Lane Plymouth,MN 55441 612-551-0901 Edina Plastic Surgery 4210 Highway 71 North Bemidji,MN 56601 218-751-6127 Red Wing 303 East Nicollet Blvd.#330 Bumsville,MN 55337 612-435-711 Coon Rapids Urgent Care-Interstate Medical Ctr Duluth Suburban Radiological Consultants 2835 S Service Drive Red Wing,MN 55066 612.388.3503 Duluth Clinic 3960 Coon Rapids Blvd#102 Coon Rapids,MN 55433 612-427.9440 Roseville 400 East 3rd St Duluth.MN 55805 218-725-3156 Duluth Urgent Care-Roseville Edina Duluth Radiologists,P.A. 1050 West Larpmteur Roseville,MN 55113 612.488.7297 Adson&Fasching Plastic Surgery,P.A. 824 Medial Arts Bldg Duluth,MN 55085 218.7=4185 Virginia 6545 France Ave.So.4240 Edina,MN 55435 612.920-2600 Edina Urgent Care-East Range Clinics Associates In Plastic Surgery,P.A. Cenntennial Lakes MRI-Consulting Rad.Ltd 910 N.6th Ave.Virginia,MN 55792 218-741-0150 6545 France Ave.S.#586 Edina,MN 55435 612-322-1111 7373 France Ave So 0101 Edina,MN 55435 612431-9300 Edina Plastic Surgery Consulting Radiologists,Ltd. 3625 West 65th Street Edina,SLY 55435 612-92$-1765 6545 Francs Ave So#302 Edith MN 55435 612.927-1017 Fargo Suburban Radiological Consultants MeritCare Medical Group 7373 France Ave So#204 Edina,MN 55345 6124934588 737 Broadway Fargo,ND 58123 701-234-2000 6545 France Ave So#471 Edina,MN 555435 612427-4689 Mankato Fridley Mankato Clinic Suburban Radiological Consultants '30 East Main St Mankato,MN 56002 507.625-1811 500 Osborne Rd#240 Fridley,MN 55432 612-786-9460 .obbinsdale Minneapolis Adson&Fasching Plastic Surgery,P.A. Consulting Radiologists,Ltd 3366 Oakdale Ave.No.4519 Robbinadale,MN 55422 612-520-7880 2425 Chicago Ave So 4306 Minneapolis,MN 55404 612471-1951 Associates In Plastic Surgery,P.A. Consulting Radiologists,Ltd. 3366 Oakdale Ave.N.4408 Robbinsdale.MN 55422 612-522-1111 920 E 28th St#240 Minneapolis,MN 55407 612.863-3850 710 E 24th St#204 Minneapolis,MN 55404 612.336-5380 Podiatry 825 So 8th St#220 Minneapolis,MN 55404 612.333-4634 Bemidji St.Cloud Bemidji re Clinic Bemidji Center for Diagnostic Imaging' J 148 Second St So St Cloud.MN 56387 612-251-0609 123334th Street NW Bemidji,MN 56601218-759.5000 St.Cloud Radiology,P.A. Burnsville 1406 6th Avenue No.St.Cloud,MN 56303 612255.5619 Burnsville Foot Clinic St.Louis Park 12940 Harriet Ave So#210 Bumaville,MN 55337 612-890-4061 Duluth Center for Diagnostic Imaging 5775 Wayzata BLvd#190 St Louis Park.,MN 55416 612-542-8553 Duluth Clinic St.Paul 400 East 3rd St Duluth,MN 15805 218-725-3156 Center for Diagnostic Imaging Fargo 910 Sibley Memorial Hwy St Paul,MN 55118 612-455-5500 MeritCare Medical Group Midwest MRI 737 Broadway Fargo,ND 58123 701-234-2000 250 Thompson St St Paul.MN 55102 612.297-0493 Glencoe St.Paul Radiology Nichols,DPM,William N. 350 St Peter St#950 St Paul,MN 55102 612-728-9160 705 East 18th St Glencoe.MN 55336 612-864-3121 Urgent Care Hastings River Valley Clinic,P.A. Anoka 1210 W.First St Hastings,MN 55033 612-438-1800 Mork Clinic Mankato 1833 2nd Avenue South Anoka,`4155303 612.421-3680 Mankato Clinic Coon Rapids 1230 East Main St Mankato,MN 56002 507.625-1811 Urgent Care-Coon Rapids Medical Ctr erham 9055 s peingbrook Drive Coon Rapids,MN 55433 612-780.1000 MeritCare Clinic Perham Duluth 665 3rd Street SW Perham.MN 56573 218-346-4040 Urgent Care-ReadyCare St.Luke's Hospital 915 East 1st St.Duluth,MN 55805 218-126-5555 Preferred WorkCare: All Providers by Specialty 2I-Jun-94 36 • 0-0 Berkle Administrators a member of the Berkley Risk Management Services Group 8441 Wayzata Boulevard PO Box 59143 Minneapolis Minnesota 55459-0143 (612) 544-0311 May 19, 1994 ing City of Oak Park Heights hts MAY PO Box 2007 i'IA{ 2 0 1994 +� Oak Park Height Mn 55082-2007 RE: Workers ' Compensation Renewal We have received your Notice of Premium Options along with payment. Enclosed is the Notice of Premium Refund Options. Please select one option and return at your earlist convenience. If you have any questions please feel free to contact me (612) 544-0311 , ext 332. Thank you for your cooperation in this matter. Sincerely, —72) 017,4';(1 Denise Potvin Underwriting Department enclosure Self-Funded Insurance Specialists An Equal Opportunity Employer • l • ' Lee of Minnesota Cities Insure Trust ,t/2---_C. Group Self-Insured Workers' Compensation Plan Administrator Berkley Administrators a member of the Berkley Risk Management Services Group P.O. Box 59143 Minneapolis, MN 55459-0143 Phone (612) 544-0311 NOTICE OF PREMIUM OPTIONS FOR STANDARD PREMIUMS OF$25.000—$50.000 The "City" Agreement No.: 02-000729-8 OAK PARK HEIGHTS Agreement Period: From: 07/07/1994 PO BOX 2007 To. 07/07/1995 OAK PARK HEIGHT MN 55082-2007 Enclosed is a quotation for workers' compensation deposit premium. Deductible options are now available in return for a premium credit applied to your estimated standard premium of$ 26538. . The deductible will apply per occurrence to paid medical costs only. There is no aggregate limit. As an alternative,cities with a standard premium in excess of$25,400 may select from several retro-rated premium options. The final net cost under the retro-rated option equals the audited standard premium times the minimum factor plus losses and all loss-related costs, not to exceed the audited standard premium times the maximum factor. The net cost for each retro option based on your estimated payroll, would be between the minimum and maximum amounts shown below, depending upon your losses. Adjustments will be made six months after the close of your agreement year and annually thereafter until all claims are closed. These adjustments will be based on audited payroll amounts and reserved as well as paid losses. Please indicate below the premium option you wish to select. You may choose only one and you cannot change options during the agreement period. OPTIONS NET DEPOSIT PREMIUM 1 [( Regular Premium Option / 92. :�jb!��" (p Deductible Options: 44 Deductible Premium Credit per Occurrence Credit Amount 2 ❑ $250 2% 531. 23961. 3 ❑ 500 4% 1062. 23430. 4 ❑ 1,000 5% 1327. 23165. 5 ❑ 2,500 9% 2388. 22104. 6 ❑ 5,000 12% 3185. 21307. 7 ❑ 10,000 17% 4511. 19981. Retrospectively Rated Premium Options: Retro-Rated Minimum Maximum Maximum (See#1 above Minimum Factor Premium Factor Premium for net deposit 8 ❑ 69.9% 18550. 115% 30519. premium) 9 ❑ 66.9% 17754. 125% 33173. 10 ❑ 61.2% 1 6241. 150% 39807. This should be signed by an authorized representative of the city requesting coverage. One of the above options must be selected. Please return a signed copy of this notice to the Administrator with payment and make checks payable to the LMCIT. . /?- %4L ignature Title Date For more information on the premium options that apply to your city, refer to the enclosed brochures. BA 4502CG (4/93) • tri Berkley Administrators a member of the Berkley Risk Management Services Group 8441 Wayzata Boulevard PO Box 59143 Minneapolis Minnesota 55459-0143 (612) 544-0311 Rolland Jerome Staberg 1418 Stagecoach Tr Afton MN 55001 • Date 1/13/94 Claim No. 244495-P8 Date of Injury 1/6/94 Employer Oak Park Heights We have received a First Report of Injury from your employer indicating that you may have received a work related injury and may be eligible for workers' compensation benefits. Please thoroughly complete the reverse side of this form, being as specific as possible, and return it promptly. In doing so, you will have provided information to aid in processing your claim. Self-Funded Insurance Specialists r !ATEMENT OF FACT Name Address: Street City State Zip Phone EMPLOYEE Rolland J. Staberg, 1418 Stagecoach Trl. , Afton. MN 55001 (612) 436-8538 at f i th Marit I,Sta s Social Security No. —��— 'Ling�e 474-46-2959 Name of Employer Name of Foreman/Supervisor EMPLOYMENT City of Oak Park Heights Roger Benson No. of Hours Worked No. of Days Worked Wages Per Per Day 8 Per Week 40 14.29 Hour Week Bhat is the nature of your present trouble, and what arts of your ody are involved? etter - Lower Backe When did the trouble first start? Give the specific date and hour. 1-6-94 11:00 a.m. Explain fully and exactly what you were doing, what happened to you at the time your trouble started, and where you were when it occurred. INJURY Backing up snowblower and slipped on ice. Give names & addresses of those who were working with you at time of injury. Jeff Kellogg Phone: 612/ 439-0550 706 W. Elm St. , Stillwater, MN 55082 When did you notify your employer? 1/7/94 Where &to whom did you report? At City DISABILITY When did you begin losing time from work? When did you return to work or when do you expect to return to work? Date: Hour: Name of Family Physician Date you first saw a doctor. Who sent you to a doctor? How many times have you been to the doctor? Are you still receiving treatment? Are you now fully recovered? If you are still having trouble, explain fully the nature of the trouble. MEDICAL Did you hurt any other part of your body? Elbow Give names & addresses of all doctors you have seen. Name Address Name Address Have you had similar trouble in the past? Give name of employer at time prior trouble occurred if work related. Describe nature of that trouble and dates of occurrence. Give names and addresses of doctors who treated you for that trouble. PAST Name Address HISTORY Name Address Name Address What other injuries have you had in the past? Give dates of previous injuries. Have you ever had a If so, what company handled your claim? workers' compensation claim? SIGNATURE Signature of Employee. Date Signed. BA 161 (3/91) . . MINNESOTA WORKERS' COMPENSATION ASSIGNED RISK PLAN Policy Administrator EMPLOYERS INSURANCE OF WAUSAU A Mutual Company Certificate of Insurance This is to certify that the insurance policies (described below by a policy number) written on forms in use by the company have been issued. This certificate is not a policy or a binder of insurance and does not in any way alter, amend or extend the coverage afforded by any policy referred to herein. ISSUED TO NAME AND MAILING ADDRESS OF INSURED AGENT OF RECORD ISSUING DATE CITY OF OAK PARK HEIGHTS A TRUST DAN SCHMICKLE 01 04 94 14168 N 57TH ST PO BOX 712 12805 HWY 55 STE 115 STILLWATER MN 55082 CHANHASSEN MN 55317 PLYMOUTH MN 55441 Policy Policy Effective Date Expiration Date Type of Insurance Policy Number (MO/DA/YR) (MO/DA/YR) Workers Compensation 0315 00 111749 01 06 94 01 06 95 SPECIAL PROVISIONS/LOCATIONS/SPECIFIED AUTOS: THIS POLICY PROVIDES COVERAGE FOR MINNESOTA EXPOSURE ONLY. EACH ACCIDENT $100,000/DISEASE POLICY LIMIT $500,000/DISEASE EACH EMPLOYEE $100,000 Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policy (policies) described above is subject to all of the terms, exclusions and conditions of such policy (policies) during the term(s) thereof. PRODUCER N0. ISSUING OFFICE REGION 0929 PO BOX 1357 MPL ° ,�� MINNEAPOLIS MN 55440-1357 (612) 830-1700 ,/ Signed Authorized Company Representative DR. RONALD E. KRANZ, D.C. 1058 CURVE CREST BOULEVARD STILLWATER, MINNESOTA 55082 PHONE 439-6500 December 17, 1993 Dear Mr. Benson, Mr. Rolland Staberg is under my care for an acute lumbar strain due to an industrial injury of 12/6/93. Due to the nature of this condition, I have advised Mr. Staberg to rest another 48 hours. If his condition continues to improve, the patient will be able to resume his work duties, Monday, December 20, 1993. I will re-examine him on December 20, 1993 and advise you of his condition. If you have any questions with regards to this matter, please contact me. Sin re flei/ r R. E. Kranz, D. . REK:fk DICTATED BUT NOT READ 410 4/0 202 MAYOR AND COUNCILMEN SALARIES WORKMAN'S COMPENSATION AN ORDINANCE PROVIDING FOR WORKMAN 'S COMPENSATION BENEFITS AND ESTABLISHING THE SALARIES OF THE MAYOR AND COUNCILMEN OF THE CITY OF OAK PARK HEIGHTS , WASHINGTON COUNTY, MINNESOTA. THE CITY COUNCIL OF THE CITY OF OAK PARK HEIGHTS, WASHINGTON COUNTY, MINNESOTA DOES ORDAIN: 202 . 01 Workman' s Compensation. The Mayor and Councilmen of the City of Oak Park Heights are hereby entitled to receive compensation from the City in accordance with the provisions of the Workman ' s Compensation Law of the State of Minnesota. If the Mayor or any Councilman sustains an injury or illness, covered by law, not caused by his intoxication or willful misconduct and not intentionally self- inflicted, which with or without negligence is proximately caused by and arises out of and in the course of performance of his duties as such Mayor or Councilman, he or his dependents shall be entitled to the maximum benefits provided under the compensation law upon the date of such injury or illness. 202 .02 Salaries. Commencing on the first business day of January, 1989, the salary of the Mayor of the City of Oak Park Heights shall be Two Hundred Fifty ($250 . 00) Dollars per month, and the salaries of Council members shall be Two Hundred ($200 . 00) per month. 202 .03 Effective Date. This ordinance shall be in full force and effect from and after its passage and publication as provided by law. • 0.44441Z/1. City Clerk r! Mayor /�