To enroll in either our NDPERS Diabetes Management Program or our WSI Pain Management Program, please fill the form out below. For a printer-friendly version, click below. Print Enrollment Form Your Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthday* MM DD YYYY Email* Daytime Phone*Evening Phone*May we call you at work?*YesNoHealth Insurance ID Number*Who do you see for your Health Care?Health Provider*Location (Clinic/Hospital)*Please Select a program locationDiabetes Program Location--Churchill Pharmacy, 1190 W Turnpike Ave, BismarckDakota Pharmacy, 705 E Main Ave, BismarckGateway Health Mart - North, 3101 N 11th St, BismarckGateway Health Mart - South, 835 S Washington St, BismarckGateway Health Mart-Sunrise, 3103 Yorktown Drive, BismarckSanford Retail Pharmacy, 300 N 7th St, BismarckThe Medicine Shoppe, 1304 E Blvd Ave, BismarckWhite Drug #5, 117 N 5th St, BismarckCentral Pharmacy, 990 Main St, CarringtonWhite Drug #53, 201 E 3rd Ave S, CavalierBell Pharmacy (Thrifty White #47), 323 5th ST NE, Devils LakeWhite Drug #63, 425 College Dr S, Devils LakeND Pharmacy, 446 18th St W, DickinsonThe Medicine Shoppe #0541-1571 W Villard St, DickinsonChurchille Pharmacy, 509 Main St, EdgeleyEllendale Pharmacy, 117 Main St, EllendaleFamily Health Care Pharmacy, 301 NP Ave, FargoFamily Health Care Pharmacy South, 4025 9th Ave S, FargoLinson Pharmacy, 3175 25th St S, FargoSouthpoint Pharmacy, 2400 32nd Ave S, FargoThe Medicine Shoppe #80, 1605 S University Dr, FargoThe Medicine Shoppe #1169, 2800 N Broadway, FargoWhite Drug #39, 1401 33rd St SW, FargoThrifty Patient Care Center, 706 38th St NW, FargoForman Drug Inc., 330 Main St S, FormanChurchille Pharmacy Glen Ullin, 113 S Main St, Glen UllinThrifty White #65, 544 Hill Ave, GraftonAltru Family Medicine Residency Pharmacy (FMR), 725 Hamline St, Grand ForksAltru Retail Pharmacy, 1200 S Columbia Rd, Grand ForksAltru Clinic/Family Medicine Center (FMC), 1380 S Columbia Rd, Grand ForksInspire Pharmacy, 360 Division Ave STE 100, Grand ForksThrifty White Drug #9, 2475 32nd Ave S, Grand ForksThrifty White Drug #81, 1395 C S Columbia Rd, Grand ForksWall's Medicine Center, 708 S Washington St, Grand ForksWhite Drug #55, 112 S Main St, HettingerHillsboro Drug, 13 N Main St, HillsboroMedicine Shoppe #545, 703 1st Ave S, JamestownWhite Drug #45, 310 First Ave S, JamestownCHI St Alexius Pharmacy, 2500 Sunset Dr NW, MandanGateway Health Mart, 500 Burlington St SE, MandanThrifty White #43, 511 First St NW, MandanB&B Northwest/Keycare Pharmacy, 20 Burdick Exp, MinotThrifty White #40, 2700 8th St NW, MinotWhite Drug #17, 1015 S Broadway, MinotCentral Pharmacy, 4 N 8th ST , New RockfordChurchill Pharmacy New Salem, 509 Ash Ave, New SalemTara's Thrifty White, 610 Main Ave, OakesYeOld Medicine Center, 503 Park St W, Park RiverThrifty White #58, 208 Main Street, RoletteWhite Drug #50, 107 2nd ST SE, RugbyThrifty White #60, 148 S Central Ave, Valley CityCentral Ave Pharmacy, 323 N Central Ave, Valley CityNuCara Pharmacy, 234 Central Ave N, Valley CityCorner Drug Store, 619 Dakota Ave, WahpetonThrifty White #75, 387 11th St S, WahpetonWhite Drug #46, 1100 13th Ave E, West FargoService Drug Pharmacy, 317 Main, WillistonTerms Complete a health history as well as an information release so your provider can talk to your doctor. Schedule your first visit within 7 days of acceptance and complete first visit within 30 days. A 24 hour notice should be given to your provider if you are unable to make a scheduled appointment unless it is an emergency situation then let them know as soon as possible. You may change your provider or discontinue the program at any time. Discontinuation of the program will stop all co-pay reimbursement. Anyone currently enrolled in Medicare Part D is not eligible for this program. Benefits One on one time with pharmacists. Reimbursement on copayments for diabetes medications, testing supplies and certain medicines used for kidney safety while in the program. Acceptance* I understand the above requirements to become a participant in the About the Patient Program. I agree to follow the above terms and understand that not following may result in my removal from the program. Comments/QuestionsPhoneThis field is for validation purposes and should be left unchanged.