Site Navigation

WCB Home Page
Change Font Size
Glossary of WCB Terms

List of Available Forms for Health Care Providers


A User ID and Password is required to submit these online forms.

If you would like to request a user ID and password please complete the online application to register for Web Submission of Medical Forms.

Please Note: User IDs and passwords may only be created for NYS licensed, Workers' Compensation Board (WCB) authorized Health Care Providers (HCP) and NYS licensed Occupational and Physical Therapists. The user ID and password are associated directly to the HCP's WCB Board authorization number or Occupational/Physical Therapists NYS license number. Use of the user ID and password are considered to be the legal equivalent of the HCP actually signing the form by hand.

To access a form, select the form number or title. A login screen will prompt you for your user ID and password.

After successful submission, a confirmation of receipt by the Board and printable Adobe PDF version of the form will appear in your web browser. You will need to keep a copy of the Adobe PDF form and provide copies to other interested parties.

New Adobe Format Overview/Features

The New C-4 Family of Forms: Frequently Asked Questions

Forms Submitted by Health Care Providers
Form Number Form Title Registration required? Comments
C-4 Doctor's Initial Report Yes Use this form to report the first time you treated the claimant.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4 filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
C-4.2 Doctor's Progress Report Yes Use this form to report continuing services.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4.2 filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
C-4.3 Doctor's Report of MMI/Permanent Impairment Yes Note: The current electronic version of the C-4.3 will continue to be available for on-line submission. We plan to release the revised version on or before February 1, 2012.

Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4.3 filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
EC-4 AMR

Web Submission Process Overview
Ancillary Medical Report Yes This form may be used to file reports for ancillary medical services such as x-ray, pathology or diagnostic services by other than the attending provider in workers' compensation, volunteer firefighter's or volunteer ambulance workers' benefit cases.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4 AMR filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
EC-4NARR

Web Submission Process Overview
Doctor's Narrative Report Yes This form may be used to report the first time you treated the patient or to report continuing services. (To report permanent impairment,use Form C-4.3.)

Use this form only if attaching a detailed narrative report. See Attachment Requirements for topics that must be addressed in the narrative attachment.

Health Care Provider must be authorized by the NYS Workers' Compensation Board.

Every EC-4NARR filed with the Board is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
NEW
OT/PT-4
Occupational Therapist's/ Physical Therapist's Report Yes 48 hour initial report, within 48 hours of first treatment.

15 day report, within 17 days of first treatment.

45 day progress report, at 45 day intervals while continuing treatment.

Every EOT/PT-4 filed with the Board is electronically signed by a NYS licensed occupational therapist or physical therapist in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).

 

If the form you are looking for is not available for online submission, you may print the PAPER version of the form from our list of common forms.