Enrollment

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.

Your Name*
First Last
Address
Street Address Address Line 2 City State ZIP Code
Birthday*
Month
Day
Year
Email*
Daytime Phone*
Evening Phone*
Health Insurance ID Number*
Who do you see for your Health Care?
Health Provider*
Location (Clinic/Hospital)*
Please Select a program location
Diabetes Program Location
Terms
- 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/Questions
Email
This field is for validation purposes and should be left unchanged.