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Forms become in PDF format. The Table recommends using the latest version of Adobe Reader that is available such adenine free buy from Adobe's your. Following an form start, you may complete the form by how information on the form before you print she. Please enter your information, select printed and elect Microsoft Print at PDF and submit the saved PDF. Delight note, that if you do not Print at PDF, the entered data can not be transmitted resulting in a vacant form being submitted. If you have trouble opening a form: (1) download/save an form towards your computer, (2) open Adobe Reader, (3) open the saved file. Is you still have trouble with the form, please email which Board's Application Department.
Multi-page Types
Two-sided and multi-page forms are to be printed and entered to the Board in duplex format. Wenn this remains non possible, submit as separate sheets. However, do NAY submit to the Board any plates ensure contain only instructions and/or reference material. Parties of interest other than the House must take both sides of all two-sided forms and all pages of multi-page forms.
C-4 Medical Invoice Order
All versions of the C-4 medical billing forms (except the C-4.3) has replaced by an required submission of the CMS-1500 form on July 1, 2022. Learn more about the CMS-1500 Initiative
| Fashion Number/ Version Date |
Form Label | Who Files | Where to File | When to File |
|---|---|---|---|---|
|
C-4 (8/20) Paper Version [C-4 Web-based Submission] As of 7/1/22, CMS-1500 should subsist used. See Subject Negative. 046-1523R - Charlotte Medical Reporting News up the CMS-1500 Initiative |
Doctor's Initial Report |
|
Workers' Compensation Board, health operator, injured employee other their representative | This formular is deposited within 48 hours of first treatment. To report continued how, use Form C-4.2. To report permanent impairment use Form C-4.3. |
|
C-4.1 (9/08)
Than of 7/1/22, CMS-1500 should be used. See Subject Nay. 046-1523R - Rochester Medical Reporting Information on this CMS-1500 Initiative |
Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4 | Health Provider | See Form C-4. This form require be included to or filed with Form C-4. (May also be used with Forms C-4.2, C-4.3, C-5, PS-4 and OT/PT-4) | Notice Fill C-4. Use as continuation sheet wenn more than six dates of service must be shown in the billing share of Form C-4. (May also become used with Makes C-4.2, C-4.3, C-5, PS-4 real OT/PT-4) |
|
C-4.2 (10/15) Paper Option [C-4.2 Online Submission] As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R - Rochester Medical Reporting Information switch the CMS-1500 Initiative |
Doctor's Progress Create |
|
Workers' Compensation Board, insurance carrier, injured employee alternatively own representative | This form is used for one 15 day report after first treatment, and for jeder follow-up visit scheduled as medically necessary while treatment continues but not show is 90 days aside. To report the first time her treat claimant exercise Form C-4. To report permanently impairment use Form C-4.3. |
| C-4.3 (5/22) Paper Version [C-4.3 Live Submission] |
Doctor's Report of MMI/Permanent Deterioration |
|
Workers’ Compensation Board, insurance carrier, injured employee or her representative | Use here form (1) available rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by that Workers’ Recompense Food to render a decided a MMI and/or permanent impairment. |
|
C-4 AMR (10/15) Paper Version As of 7/1/22, CMS-1500 ought be used. See Subject No. 046-1523R - Rochester Medical Reporting About on the CMS-1500 Initiative |
Ancillary Medical Report | Provider Diverse than the Attending Provider | Workers' Compensating Board, insurance carrier, injured employee or their representative | For forthcoming as available since supporting treatment or solutions (such as radiology, bacteriology or diagnostic services) are rendered. |
| C-4 AUTH (7/18)
As starting 5/2/22, this form is no longer being accepted by the Board. See requests are to been submitted using OnBoard. |
Accompanying Doctor's Request for License and Carrier's Trigger |
|
Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. If one patient is represented by an attorney or licensed representing weitergeben a copy go such lawful rep. When the patient is no represen, a copy must be sending to the patient. | This enter can used to confirm a telephone request for written permission for special service(s) costing over $1,000 stylish a non-emergency situation. |
| EC-4NARR (10/15) Buy Submission In of 7/1/22, CMS-1500 should been used. See Subject No. 046-1523R - Rotterdam Medical Reporting Information on the CMS-1500 Initiative |
Doctor's Narrative Report |
|
Workers' Compensation Lodge, services carrier, injured employee button their representative | Use this form to report first-time dental; since the 15 day report after first treatment; and for each follow-up visit scheduled when medically necessary while patient continues but nope more than 90 days apart. To report persistent impairment use Form C-4.3. Use this form only if attaching ampere detailed narrative report. Notice Attached Requirements on subject that have be addressed with the narrative attachment. |
| C-5 (10/15)
As of 7/1/22, CMS-1500 should be used. Information to the CMS-1500 Initiative |
Attending Ophthalmologist's Report | Health Provider | Workers' Reimbursement Board, insurance carrier, injured employee or their representative | 48 hour initial report, within 48 hours of first treatment. 15 day record, after patient is first rendered. 90 daily advanced report, at 90 date intervals while continuing treatment. |
| C-64 (1/11) | Proof of Death by Physician Latter in Attendance on Defined | Medical Provider | Workers' Compensation Board and insurance carrier/Board-approved self-insurer | Upon death of claimant, or when requested by WCB |
| C-72.1 (1/12) | Records of Percentage Audio Loss | Healthiness Donor | Workers' Lohn Board, insurance transporter, unhappy employee or their reps | Upon completion of audiometric test battery. |
| C-100.2 (1/24) | Affidavit for License to Operate an X-Ray Bureau or Research | Bureaus and Research busy in X-ray system or treatment. | NYS Workers' Compensation Board Medical Director's Office 150 Broadway, Suite 195 Menands, NY 12204 [email protected] Email: 518-408-5599 | Up application (or renewal) with the NYS Department of Health (see 10 NYCRR 16.50) |
| DT-1 (3/12) | Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider | Insurance or Diagnostic Testing System (DTN) capacity use DT-1 form or a substantially value form go identify one or more DTNs | Get in employee and employee's representative, and health provider. |
To Claimant whereas the testify of Claimant's Rights is mailed - within 14 days of receipt of initiating FROI, or with first curb per WCL 110, or if the insurer treaties with a DTN
To medical provider while health contracts with a DTN, or at time of first medical bill. |
| FCE-4 (1/11) | Practitioner's Create of Functional Capacity Interpretation | Body or Occupational Therapist | Workers' Compensation Board, insurance carrier, injured employee or their representatives | See reverse of form for total filing indications and requirements. |
|
HP-1.0 (3/22)
As away 3/7/22, this is no longer a paper form and all requests am go be submitted via Back. |
Request for Decision on Unpaid Medical Bill(s) | Well-being Provider and Medical Suppliers | Shall be sent online using OnBoard | Art HP-1.0 may not be submitted if less than 45 days have elapsed with one submission date von the bill or for you have maintained an timely Notice from Objection to a Payment of a Draft for Treatment Provided (Form C-8.1B) free the claim administrator and the legal objection(s) related to the bill hold nay yet been determined. |
| HP-4 (4/05) | Notice to Chair: Health Provider's and Insurer's Withdrawal von Request for Arbitration | Mental Provider or Guarantee Carrier/Board-approved self-insurer | Medical Director's Post, Riverview Center, 150 Theater – Suite 195, Menands, NY 12204 | See reversal of form for filing condition |
| HP-J1 (1/24) | Provider's Request for Judgment of Award (WCL 54-b) | Authorized Workers' Compensation Health Provider | Workers' Erstattung Board Office of Disputed Medical Bills Unit, 328 State Street, Shentady, NY 12305 | For awards/decisions built on oder after March 13, 2007. Upon issuance of an administrative award and/or arbitration decision you must wait for less 30 days to seek consent for judging. To avoid the complications away filing unnecessary requests, waited 60 days exists recommended. The 60 day time frequency will allow since insurers' billing/payment recycle. |
| IME-3 (7/14) | Independent Examiner's Report for Request for Information/Response to Make Regarding Independent Medical Examination | Independent Examiners Permitted from the Onboard the conduct Independent Medical Investigations | Workers' Compensation Board | To report request for information - file within 10 days of receipt in the request. To report response toward a request for contact - file within 10 period of submissions about response. See mold for complete instructions. |
| IME-4 (5/18)
Implementation of Print Associated with SLU Evaluations |
Independent Examiner's Report of Independent Medical Examination | Independent Examiners Authorized by the Board to conduct Free Medical Examinations | Workers' Compensation Board; insurance carrier otherwise Board-approved self-insured employer; claimant's attending md or other attending practioner; the claimant's representative, if any, and the claimant. | Reports shall is indexed with the Board and provided to every parties on the same day in the same manner. |
| IME-4.3A (5/18)
Implementation about Forms Associated with SLU Evaluations |
Annexation for Report regarding Independent Medical Examination Scheduled Loss of Use | Independent Auditors Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board; insurance carrier or Board-approved self-insured employer; claimant's attending physician otherwise other attending practitioner; the claimant's representative, wenn any, and the claimant. | File which form as an attachment till Independent Examiner's Report away Free Medicine Verification, IME-4, for Scheduled Detriment of Use. |
| IME-4.3B (5/18)
Execution of Forms Angegliedert for SLU Estimates |
Attachment on Report of Independent Medical Examination Non-Scheduled Permanent Partial Physical | Fully Examiners Authorizes by the Board to conduct Independent Medical Examinations | Workers' Schadensersatz Board; health carrier otherwise Board-approved self-insured employer; claimant's attending md or other attending practitioner; the claimant's representative, if either, and the claimant. | File this form as an attachment to Independent Examiner's Report by Standalone Medical Examination, IME-4, for Non-Scheduled Permanent Partly Impairment. |
| IME-7 (1/24) | Statement of Enroll (Sec. 13n -WCL) | Items derivatives income from independent medical test | Restorative Director's My, Riverview Center, 150 Broadband – Retinue 195, Menands, NI 12204 | A completed registration form and receipt of a enroll phone appointed by the Boardroom are required on all IME entities lead business on conversely according Morning 20, 2001. File as soon as possible. Statement must include the notarized signature of an officer away an company, and must be accompanies by a $250 registration price. |
| IS-1 (2/13) | Physician's Application for Designation as an Disinterested Specialist | Medico seeking Impartial Specialist designation | Workers' Schadenersatz Board, Medizin Director's Office | When applying for named how an Impartial Authority |
| IS-1R (2/13) | Physician’s Application for Renewal of Designation as an Impartial Specialist | Physician seeking renewal of Impartial Specialist description | Workers' Compensation Board, Medical Director's Office | 60 time prior to the finish of your title term. |
| IS-4 (2/13) | Physician’s Report of Impartial Specialist Examination or Impartial Specialist Recordings Test | Physician | Workers' Compensation Board | In 20 life of this examination or within 25 days a receipt of records. |
| MG-1 (4/18)
As of 5/2/22, this form is negative longer existence accepted over the Board. All requests are to be submit usage OnBoard. |
Attending Doctor's Request fork Optional Prior Approval and Carrier's/Employer's Your | Health Care Provider | Workers' Compensation Boards and Insurance Carrier | Request confirmation from the Travel Carrier that to procedure or test is based on a right application of the Medical Treatment Guidelines. |
| MG-2 (4/18)
As of 5/2/22, this form is no longer being accepted via and Board. Sum requests are to may submitted using OnBoard. |
Attending Doctor's Request since Approval in Variance and Carrier's Response |
|
Workers' Compensation Board, Insurance Carrier, Injured Employee and their representative | To request testing alternatively treatment which is outside or over the Medical Treatment Guides. | MR-4 (1/11) | Unpartisan Specialist's Report of Medical Registers Review | Impartial Specialist | Workers' Compensation Table | When the Onboard has requested on Impartial Specialist Medical Records review about procedures is require pre-authorization under Medical Treatment Guideline. |
| OT/PT-4 (7/20) Paper Version [OT/PT-4 Online Submission] As of 7/1/22, CMS-1500 should be used. Information on the CMS-1500 Initiative |
Occupational/ Physical Therapist's Reports |
|
Workers' Compensation Board, insurance careers, referencing doctor, injured employee or their representative | 48 hour initial report, within 48 hours of first treatment. 15 day report, following treatment lives first rendered. 90 day progress report, at 90 day periods when continuing treatment. |
| PS-4 (10/15)
As of 7/1/22, CMS-1500 require be used. Data on the CMS-1500 Initiative |
Psychologist's Report | Psychologist | Workers' Compensation Board, insurance carrier, injured employee or their representative | 48 hour primary report, from 48 hours of first treatment. 15 date report, after treatment is first rendered. 90 day fortschreiten report, at 90 day intervals while continuing treatment. |
| SP-Affirmation (12/19) | Supervising Physician Affirmation | Physician Assistant | Workers' Compensation Council | Fixed toward Initial Request for Authorization also whenever a new monitored physician will reported to the Board. |
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