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Forms Submitted by Attorneys and Licensed Representatives

Form Number	Form Title	Registration required?	Comments
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted (C-7) cases.
RFA-1LC	Request for Further Action By Legal Counsel	No	The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORM C-89.3. Note:When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name and date of injury.
VDF-1	Loss of Wage Earning Capacity Vocational Data Form	No	Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

 

Forms Submitted by Employers

Form Number	Form Title	Registration required?	Comments
C-2	Employer's Report of Work-Related Injury/Illness	No	Must be filed within ten days after occurrence of accident.
C-11	Employer's Report of Injured Employee's Change in Employment Status Resulting From Injury	No	As soon as employment status of injured employee changes.
C-240	Employer's Statement of Wage Earnings	No	Within 10 days of request by the Board.
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted (C-7) cases.
RFA-2|	Request for Further Action By Carrier/Employer	No	The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORMS C-89.3, C-22B, CB-8 AND RB-679. Note: When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name and date of injury.

 

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).
C4.2 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).
C4AMR 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).
C4NARR 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).
OT/PT-4 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).

 

Forms Submitted by Injured Workers

Form Number	Form Title	Registration required?	Comments
C-3	Employee Claim	No	Must be filed within two years of injury, or within two years after employee knew or should have known that injury or illness was related to employment.
RFA-1W|	Request for Assistance By Injured Worker	No	The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORM C-89.3. Note:When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, injured worker name and date of injury.
VDF-1	Loss of Wage Earning Capacity Vocational Data Form	No	Injured Workers who may have a non-schedule permanent impairment and who have not returned to work are encouraged to complete and submit Form VDF-1 as early as possible in the claim.

 

Forms Submitted by Insurance Carriers, Self-Insured Employers
and Third Party Administrators

Form Number	Form Title	Registration required?	Comments
C-2	Employer's Report of Work-Related Injury/Illness	No	Must be filed within ten days after occurrence of accident.
C-7	Notice that Right to Compensation is Controverted	Yes	Must be filed on or before 18th day after disability or within 10 days after employer had knowledge of injury, whichever is greater.
C-8/8.6	Notice that Payment of Compensation has been Stopped or Modified	Yes	Must be filed within 16 days after the date on which benefit payments were stopped or modified.
C-8.1	Notice of Treatment Issue(s)/ Disputed Bill Issue(s)	Yes	Treatment issue: within 5 days after terminating medical care or refusing authorization. Disputed bill: within 45 days of submission of bill.
C-669	Notice to Chair of Carrier's Action on Claim for Benefits	Yes	IF PAYMENT HAS BEGUN: must be filed on or before 18th day after disability, or within 10 days after employer first had knowledge of injury, whichever is greater. IF PAYMENT HAS NOT BEGUN: no later than 25 days after the Board has mailed a Notice of Indexing.
DB-470	Preliminary/Final Claim for Reimbursement of Benefits Paid Under Disability Benefits Law	Yes	Submitted prior to award of workers' compensation benefits.
PH-16.2	Pre-Hearing Conference Statement	No	Filed ten days before scheduled pre-hearing conference for controverted (C-7) cases.
RFA-2|	Request for Further Action By Carrier/Employer	No	The form may be filed at any time after the indexing of a claim or after the Board has indicated that no further action (NFA) will be taken. REPLACES FORMS C-89.3, C-22B, CB-8 AND RB-679. Note: When filing required documents (e.g. medical evidence indicating permanency), provide the appropriate document identification if it is already in the case folder. If faxing or mailing documents, be sure that each page is properly identified by the WCB case number, claimant name and date of injury.

 

Forms Submitted by Political Subdivisions for Volunteer Firefighters and Volunteer Ambulance Workers

Form Number	Form Title	Registration required?	Comments
VF-2|	Political Subdivision's Report of Injury to Volunteer Firefighter	No	Must be filed within ten days after injury is incurred.
VAW-2|	Political Subdivision's Report of Injury to Volunteer Ambulance Worker	No	Must be filed within ten days after injury is incurred.

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