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Workers’ Compensation Board

WCB Information Related To Novel Coronavirus (COVID-19)

List of Available Forms for Health Care Providers


Please Note: It is anticipated that all versions of the C-4 medical billing forms (except the C-4.3) and the OT/PT-4 will be replaced by the required XML submission of the CMS-1500 form on July 1, 2021. Learn more about the CMS-1500 Initiative.

The health care provider must be authorized by the NYS Workers' Compensation Board.

A user ID and password is required to submit these online forms. This is the same user ID and password used to access the Board’s Medical Portal. When a form listed below is filed with the Board, it 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).

Request User ID

To sumbit a form, log in to the Medical Portal and select the link for Web Submission of Medical Forms.

Medical Portal Login

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

Form Instructions

Forms Submitted by Health Care Providers
Form Number Form Title Who Can Submit Comments
C-4 Doctor's Initial Report
  • Physician
  • Chiropractor
  • Podiatrist
  • Nurse Practitioner
  • Licensed Clinical Social Worker
Use this form to report the first time you treated the patient.
C-4.2 Doctor's Progress Report
  • Physician
  • Chiropractor
  • Podiatrist
  • Physician Assistant
  • Nurse Practitioner
  • Licensed Clinical Social Worker
Use this form to report continuing services.
C-4.3 Doctor's Report of MMI/Permanent Impairment
  • Physician
  • Chiropractor
  • Podiatrist
  • Psychologist
  • Nurse Practitioner
  • Licensed Clinical Social Worker
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.
EC-4 AMR

Web Submission Process Overview
Ancillary Medical Report Health Care Provider authorized by the NYS Workers' Compensation Board 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.
EC-4NARR

Web Submission Process Overview
Doctor's Narrative Report
  • Physician
  • Chiropractor
  • Podiatrist
  • Psychologist
  • Physician Assistant
  • Nurse Practitioner
  • Licensed Clinical Social Worker
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.

OT/PT-4
Occupational Therapist's/ Physical Therapist's Report
  • Occupational Therapist
  • Physical Therapist
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.

 

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.