Schema xfs-cis.xsd


element submission
diagram xfs-cis_diagrams/xfs-cis_p1.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
properties
content complex
children c4amr_0908:document c4amr_1012:document c4narr_0812:document c4narr_1012:document otpt4_1012:document
attributes
Name  Type  Use  Default  Fixed  annotation
application-idrequired    CIS  
documentation
Value is fixed at 'CIS' for this submission type.
production-test-indicatorrequired      
documentation
Indicates submission was for production use or testing only (values P or T)
bp-submission-idrequired      
documentation
Business Partner's Internal Submission ID Attribute
documentation
This is the business partner's identifier for the entire submission.
bp-submission-commentoptional      
documentation
Business Partner's Comment Attribute
documentation
Optional comment for business partner's use.
annotation
documentation
XML Form Submission (Root Element)

attribute application-id
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type wcb:Text
facets
Kind Value annotation 
minLength 
pattern [ -~]* 
annotation
documentation
WCB Application ID Attribute

attribute bp-document-comment
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:Text
facets
Kind Value annotation 
minLength 
maxLength 60 
pattern [ -~]* 
annotation
documentation
Business Partner's Document Comment Attribute
documentation
Optional document comment for business partner's use.

attribute bp-document-id
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:Text
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Business Partner's Internal Document ID Attribute
documentation
This is the business partner's 'serial number' for the document.

attribute bp-submission-comment
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:Text
facets
Kind Value annotation 
minLength 
maxLength 60 
pattern [ -~]* 
annotation
documentation
Business Partner's Submission Comment Attribute
documentation
Optional submission comment for business partner's use.

attribute bp-submission-id
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:Text
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Business Partner's Internal Submission ID Attribute
documentation
This is the business partner's identifier for the entire submission.

attribute form-id
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:Text
facets
Kind Value annotation 
minLength 
maxLength 10 
pattern [ -~]* 
annotation
documentation
Form ID Attribute
documentation
WCB form identifier.

attribute maintenance-type-code
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type wcb:Text
properties
fixed 050
facets
Kind Value annotation 
minLength 
pattern [ -~]* 
annotation
documentation
Maintenance Type Code (ANSI)
documentation
Value is fixed at '050' which is the ANSI code for 'original form'.

attribute production-test-indicator
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:Text
facets
Kind Value annotation 
minLength 
pattern [ -~]* 
enumeration 
enumeration 
annotation
documentation
Indicates submission was for production use or testing only (values P or T)

attribute source-code
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type wcb:Text
properties
fixed X
facets
Kind Value annotation 
minLength 
pattern [ -~]* 
annotation
documentation
Source Code Attribute
documentation
Value is fixed at 'X' for XML Forms Submission.

attribute version-number
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:Text
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Version Number Attribute
documentation
WCB form version number (a date in YYMM format).

element attachment-binary
diagram xfs-cis_diagrams/xfs-cis_p2.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
properties
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:content-typewcb:Textrequired      
documentation
Conent Type (MIME Type) -- only 'image/tiff' is currently allowed
wcb:refwcb:Textrequired      
documentation
A reference to the binary attachment.  This must be the filename only with no path or other prefix/suffix.
annotation
documentation
Document Attachment - Binary
documentation
This element is a placeholder which references a binary attachment which is to be inserted at the current point in the list of all attachments (binary and text).

attribute attachment-binary/@content-type
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type wcb:Text
properties
isRef 0
use required
facets
Kind Value annotation 
minLength 
pattern [ -~]* 
annotation
documentation
Conent Type (MIME Type) -- only 'image/tiff' is currently allowed

attribute attachment-binary/@ref
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type wcb:Text
properties
isRef 0
use required
facets
Kind Value annotation 
minLength 
pattern [ -~]* 
annotation
documentation
A reference to the binary attachment.  This must be the filename only with no path or other prefix/suffix.

element attachment-text
diagram xfs-cis_diagrams/xfs-cis_p3.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
properties
content complex
children wcb:page
annotation
documentation
Document Attachment - Text (Embedded)
documentation
This element contains text for one or more pages to be inserted at the current point in the list of all attachments (binary and text).
documentation
Each page can contain up to 56 lines with 100 characters each.  Note that the 'Courier 9' fixed-space font is used to create the viewable page.

element attachment-text/page
diagram xfs-cis_diagrams/xfs-cis_p4.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
properties
isRef 0
minOcc 1
maxOcc unbounded
content complex
children wcb:line
annotation
documentation
Contains contents of a single page

element attachment-text/page/line
diagram xfs-cis_diagrams/xfs-cis_p5.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:String
properties
isRef 0
minOcc 1
maxOcc 56
content simple
facets
Kind Value annotation 
minLength 
maxLength 100 
pattern [ -~]* 
annotation
documentation
One line of text

complexType Flag
diagram xfs-cis_diagrams/xfs-cis_p6.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
WCB Flag Type (Y/N)

attribute Flag/@value
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:String
properties
isRef 0
use required
facets
Kind Value annotation 
length 
pattern [ -~]* 
enumeration 
enumeration 
annotation
documentation
Value must be 'Y' or 'N'.

complexType FlagUnknown
diagram xfs-cis_diagrams/xfs-cis_p7.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y', 'N', or 'U'.
annotation
documentation
WCB Flag Type (Y/N/U)

attribute FlagUnknown/@value
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:String
properties
isRef 0
use required
facets
Kind Value annotation 
length 
pattern [ -~]* 
enumeration 
enumeration 
enumeration 
annotation
documentation
Value must be 'Y', 'N', or 'U'.

complexType Gender
diagram xfs-cis_diagrams/xfs-cis_p8.png
namespace http://www.wcb.state.ny.us/xml/ns/wcb
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'M' or 'F'.
annotation
documentation
WCB Gender Type (M/F)

attribute Gender/@value
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:String
properties
isRef 0
use required
facets
Kind Value annotation 
length 
pattern [ -~]* 
enumeration 
enumeration 
annotation
documentation
Value must be 'M' or 'F'.

simpleType Date
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type xs:date
annotation
documentation
WCB Date Type

simpleType Decimal
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type xs:decimal
annotation
documentation
WCB Decimal Type

simpleType NonNegativeInteger
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type xs:nonNegativeInteger
annotation
documentation
WCB NonNegativeInteger Type

simpleType NPINumber
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of xs:string
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
National Provider Identifier Type

simpleType NYSLicenseNumber
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of xs:string
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
New York State License Number Type

simpleType SSN
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of xs:string
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
Social Security Number Type

simpleType String
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of xs:string
facets
Kind Value annotation 
pattern [ -~]* 
annotation
documentation
WCB String Type

simpleType StringUpperCase
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of xs:string
facets
Kind Value annotation 
pattern [ -`{-~]* 
annotation
documentation
WCB String Type

simpleType Text
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:String
facets
Kind Value annotation 
minLength 
pattern [ -~]* 
annotation
documentation
WCB Text Type

simpleType TextUpperCase
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of wcb:StringUpperCase
facets
Kind Value annotation 
minLength 
pattern [ -`{-~]* 
annotation
documentation
WCB Text Type

simpleType Time
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type xs:time
annotation
documentation
WCB Time Type

simpleType WCBAuthorizationNumber
namespace http://www.wcb.state.ny.us/xml/ns/wcb
type restriction of xs:string
facets
Kind Value annotation 
pattern [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]? 
annotation
documentation
WCB Authorization Number

element addr1
diagram xfs-cis_diagrams/xfs-cis_p9.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p10.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p11.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 20 
pattern [ -~]* 
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p12.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:StringUpperCase
properties
content simple
facets
Kind Value annotation 
length 
pattern [ -`{-~]* 
annotation
documentation
3-character Country Code
documentation
Required if the associated Zip field is blank.  Element optional if country is USA.

element data
diagram xfs-cis_diagrams/xfs-cis_p13.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
content complex
children c4narr_0812:patient c4narr_0812:employer c4narr_0812:doctor c4narr_0812:billing-information c4narr_0812:opinion c4narr_0812:authorized-doctor c4narr_0812:supervised-health-care-provider
attributes
Name  Type  Use  Default  Fixed  annotation
form-idrequired    C-4NARR  
documentation
Form ID Attribute
documentation
Value is fixed at 'C-4' for this document type.
version-numberrequired    0812  
documentation
Version Number Attribute
documentation
Value is fixed at '0812' for this document type.
source-coderequired    X  
documentation
Source Code Attribute
documentation
Value is fixed at 'X' for XML Forms Submission.
maintenance-type-coderequired    050  
documentation
Maintenance Type Code (ANSI)
documentation
Value is fixed at '050' which is the ANSI code for 'original form'.
annotation
documentation
C-4NARR Discrete Data Elements (December 2008)

element data/patient
diagram xfs-cis_diagrams/xfs-cis_p14.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone c4narr_0812:wcb-case-number c4narr_0812:carrier-case-number c4narr_0812:gender c4narr_0812:date-of-birth c4narr_0812:ssn c4narr_0812:date-of-injury c4narr_0812:job-title c4narr_0812:work-activities c4narr_0812:patient-working c4narr_0812:patient-account-no
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p15.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type cis:CaseIDOld
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9A-Z][0-9A-Z][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
WCB Case ID
documentation
1st and 2nd characters must be alphanumeric.  3rd - 8th characters must be numeric.

element data/patient/carrier-case-number
diagram xfs-cis_diagrams/xfs-cis_p16.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
pattern [ -~]* 
annotation
documentation
Insurance Carrier's Case ID

element data/patient/gender
diagram xfs-cis_diagrams/xfs-cis_p17.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Gender
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'M' or 'F'.
annotation
documentation
Patient's Gender

element data/patient/date-of-birth
diagram xfs-cis_diagrams/xfs-cis_p18.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p19.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:SSN
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
Patient's Social Security Number

element data/patient/date-of-injury
diagram xfs-cis_diagrams/xfs-cis_p20.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
pattern [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9] 
annotation
documentation
Date of Injury
documentation
This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/job-title
diagram xfs-cis_diagrams/xfs-cis_p21.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 45 
pattern [ -~]* 
annotation
documentation
Patient's Job Title

element data/patient/work-activities
diagram xfs-cis_diagrams/xfs-cis_p22.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 200 
pattern [ -~]* 
annotation
documentation
Patient's Work Activities

element data/patient/patient-working
diagram xfs-cis_diagrams/xfs-cis_p23.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Patient Working Flag

element data/patient/patient-account-no
diagram xfs-cis_diagrams/xfs-cis_p24.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 15 
pattern [ -~]* 
annotation
documentation
Patient's Account No.

element data/employer
diagram xfs-cis_diagrams/xfs-cis_p25.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:name1 c4narr_0812:name2 c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone
annotation
documentation
Employer Information

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p26.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:profession c4narr_0812:wcb-authorization-number c4narr_0812:wcb-rating-code c4narr_0812:npi-number c4narr_0812:federal-id-number c4narr_0812:federal-id-type c4narr_0812:office-location c4narr_0812:billing-address
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p27.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
c4narr_0812:valuederived by: wcb:NonNegativeIntegerrequired      
annotation
documentation
Profession Indicator
documentation
Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

attribute data/doctor/profession/@value
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:NonNegativeInteger
properties
isRef 0
use required
facets
Kind Value annotation 
minInclusive 
maxInclusive 

element data/doctor/wcb-authorization-number
diagram xfs-cis_diagrams/xfs-cis_p28.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 20 
pattern [ -`{-~]* 
annotation
documentation
WCB Authorization Number
documentation
For WCB-authorized providers, this element must be populated with the number assigned to that provider by WCB.  For unauthorized, New York State-licensed providers, this element should be populated with the provider's six-digit state license number.  For non-New York State providers, this element should not be populated -- use the npi-number element instead.

element data/doctor/wcb-rating-code
diagram xfs-cis_diagrams/xfs-cis_p29.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc unbounded
content simple
facets
Kind Value annotation 
minLength 
maxLength 15 
pattern [ -`{-~]* 
annotation
documentation
WCB Rating Code(s)
documentation
This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for any unauthorized provider.

element data/doctor/npi-number
diagram xfs-cis_diagrams/xfs-cis_p30.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:NPINumber
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
National Provider Identifier
documentation
This element is required for non-New York State providers.

element data/doctor/federal-id-number
diagram xfs-cis_diagrams/xfs-cis_p31.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
SSN or EIN

element data/doctor/federal-id-type
diagram xfs-cis_diagrams/xfs-cis_p32.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
minOcc 0
maxOcc 1
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
c4narr_0812:valuederived by: wcb:NonNegativeIntegerrequired      
annotation
documentation
Federal ID Type Indicator
documentation
Set 'value' attribute as follows:  1=SSN;  2=EIN

attribute data/doctor/federal-id-type/@value
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:NonNegativeInteger
properties
isRef 0
use required
facets
Kind Value annotation 
minInclusive 
maxInclusive 

element data/doctor/office-location
diagram xfs-cis_diagrams/xfs-cis_p33.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p34.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country c4narr_0812:telephone
annotation
documentation
Billing Address Information
documentation
If billing inquires need to be sent to an entity other than the doctor, utilize the addr1 element for that name and addr2 for the address.

The next version of the this schema will include discrete elements for billing name.

element data/billing-information
diagram xfs-cis_diagrams/xfs-cis_p35.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:carrier c4narr_0812:diagnosis c4narr_0812:procedure c4narr_0812:wcb-ppo
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p36.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
minOcc 0
maxOcc 1
content complex
children c4narr_0812:wcb-carrier-id c4narr_0812:name1 c4narr_0812:name2 c4narr_0812:addr1 c4narr_0812:addr2 c4narr_0812:city c4narr_0812:state c4narr_0812:zip c4narr_0812:country
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p37.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern W[0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
WCB Carrier ID Code

element data/billing-information/diagnosis
diagram xfs-cis_diagrams/xfs-cis_p38.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
minOcc 1
maxOcc 4
content complex
children c4narr_0812:diagnosis-code c4narr_0812:diagnosis-desc
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p39.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p40.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 75 
pattern [ -~]* 
annotation
documentation
ICD9 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p41.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
minOcc 1
maxOcc unbounded
content complex
children c4narr_0812:service-from-date c4narr_0812:service-thru-date c4narr_0812:place-of-service c4narr_0812:procedure-code c4narr_0812:procedure-modifier-a c4narr_0812:procedure-modifier-b c4narr_0812:service-diagnosis-code c4narr_0812:service-charge-amount c4narr_0812:service-days-or-units c4narr_0812:service-cob c4narr_0812:service-zip-code
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p42.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p43.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Procedure Dates of Service (end of date range)
documentation
Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service
diagram xfs-cis_diagrams/xfs-cis_p44.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p45.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p46.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p47.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p48.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p49.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Decimal
properties
isRef 0
content simple
facets
Kind Value annotation 
minInclusive 0.00 
totalDigits 
fractionDigits 
annotation
documentation
Charge Amount
documentation
Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units
diagram xfs-cis_diagrams/xfs-cis_p50.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p51.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p52.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p53.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Flag
properties
isRef 0
minOcc 0
maxOcc 1
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Preferred Provider Organization Flag

element data/opinion
diagram xfs-cis_diagrams/xfs-cis_p54.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:competent-producing-cause c4narr_0812:history-consistent-complaint c4narr_0812:history-consistent-findings c4narr_0812:percent-temp-impairment
annotation
documentation
Doctor's Opinion

element data/opinion/competent-producing-cause
diagram xfs-cis_diagrams/xfs-cis_p55.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Competent Producing Cause Flag
documentation
Indicates whether or not the occurrence or occupational history described in prior elements (or in a previous report which gave this information) is the competent producing cause of the injury or disease and disability (if any) sustained.

element data/opinion/history-consistent-complaint
diagram xfs-cis_diagrams/xfs-cis_p56.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
History Consistent With Complaint Flag
documentation
Indicates whether or not the patient's complaints are consistent with the history of the injury/illness.

element data/opinion/history-consistent-findings
diagram xfs-cis_diagrams/xfs-cis_p57.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:FlagUnknown
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y', 'N', or 'U'.
annotation
documentation
History Consistent With Findings Flag
documentation
Indicates whether or not the patient's history of the injury/illness is consistent with the doctor's objective findings.

element data/opinion/percent-temp-impairment
diagram xfs-cis_diagrams/xfs-cis_p58.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Decimal
properties
isRef 0
content simple
facets
Kind Value annotation 
minInclusive 0.00 
maxInclusive 100.00 
totalDigits 
fractionDigits 
annotation
documentation
Percentage of Temporary Impairment

element data/authorized-doctor
diagram xfs-cis_diagrams/xfs-cis_p59.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
content complex
children c4narr_0812:provided-services c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:specialty
annotation
documentation
Authorized Doctor
documentation
Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services
diagram xfs-cis_diagrams/xfs-cis_p60.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Provided Services Flag
documentation
Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/supervised-health-care-provider
diagram xfs-cis_diagrams/xfs-cis_p61.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
isRef 0
minOcc 0
maxOcc 1
content complex
children c4narr_0812:last-name c4narr_0812:first-name c4narr_0812:middle-initial c4narr_0812:specialty
annotation
documentation
Supervised Health Care Provider
documentation
This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document
diagram xfs-cis_diagrams/xfs-cis_p62.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
properties
content complex
children c4narr_0812:data wcb:attachment-text wcb:attachment-binary
attributes
Name  Type  Use  Default  Fixed  annotation
bp-document-idrequired      
documentation
Business Partner's Internal Document ID Attribute
documentation
This is the business partner's 'serial number' for the document.
bp-document-commentoptional      
documentation
Business Partner's Document Comment Attribute
documentation
Optional document comment for business partner's use.
annotation
documentation
C-4NARR Document (December 2008)

element first-name
diagram xfs-cis_diagrams/xfs-cis_p63.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Name

element last-name
diagram xfs-cis_diagrams/xfs-cis_p64.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of xs:string
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [A-Za-z][ -~]* 
annotation
documentation
Last Name
documentation
First character must be alpahbetic.

element middle-initial
diagram xfs-cis_diagrams/xfs-cis_p65.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Middle Initial

element name
diagram xfs-cis_diagrams/xfs-cis_p66.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Name

element name1
diagram xfs-cis_diagrams/xfs-cis_p67.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Line of Name

element name2
diagram xfs-cis_diagrams/xfs-cis_p68.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Second Line of Name

element specialty
diagram xfs-cis_diagrams/xfs-cis_p69.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Specialty

element state
diagram xfs-cis_diagrams/xfs-cis_p70.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:StringUpperCase
properties
content simple
facets
Kind Value annotation 
length 
pattern [ -`{-~]* 
annotation
documentation
State
documentation
Required if country is USA.

element telephone
diagram xfs-cis_diagrams/xfs-cis_p71.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Telephone Number
documentation
Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip
diagram xfs-cis_diagrams/xfs-cis_p72.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_0812
type restriction of wcb:TextUpperCase
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Zip Code
documentation
Required if country is USA or Canada.

element addr1
diagram xfs-cis_diagrams/xfs-cis_p73.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p74.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p75.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 20 
pattern [ -~]* 
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p76.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:StringUpperCase
properties
content simple
facets
Kind Value annotation 
length 
pattern [ -`{-~]* 
annotation
documentation
3-character Country Code
documentation
Required if the associated Zip field is blank.  Element optional if country is USA.

element data
diagram xfs-cis_diagrams/xfs-cis_p77.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
content complex
children c4narr_1012:patient c4narr_1012:employer c4narr_1012:doctor c4narr_1012:billing-information c4narr_1012:opinion c4narr_1012:authorized-doctor
attributes
Name  Type  Use  Default  Fixed  annotation
form-idrequired    C-4NARR  
documentation
Form ID Attribute
documentation
Value is fixed at 'C-4' for this document type.
version-numberrequired    1012  
documentation
Version Number Attribute
documentation
Value is fixed at '1012' for this document type.
source-coderequired    X  
documentation
Source Code Attribute
documentation
Value is fixed at 'X' for XML Forms Submission.
maintenance-type-coderequired    050  
documentation
Maintenance Type Code (ANSI)
documentation
Value is fixed at '050' which is the ANSI code for 'original form'.
annotation
documentation
C-4NARR Discrete Data Elements (December 2010)

element data/patient
diagram xfs-cis_diagrams/xfs-cis_p78.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone c4narr_1012:wcb-case-number c4narr_1012:carrier-case-number c4narr_1012:gender c4narr_1012:date-of-birth c4narr_1012:ssn c4narr_1012:date-of-injury c4narr_1012:job-title c4narr_1012:work-activities c4narr_1012:patient-working c4narr_1012:patient-account-no
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p79.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type cis:CaseID
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
WCB Case ID
documentation
1st and 2nd characters must be alphanumeric.  3rd - 8th characters must be numeric.

element data/patient/carrier-case-number
diagram xfs-cis_diagrams/xfs-cis_p80.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
pattern [ -~]* 
annotation
documentation
Insurance Carrier's Case ID

element data/patient/gender
diagram xfs-cis_diagrams/xfs-cis_p81.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Gender
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'M' or 'F'.
annotation
documentation
Patient's Gender

element data/patient/date-of-birth
diagram xfs-cis_diagrams/xfs-cis_p82.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p83.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:SSN
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
Patient's Social Security Number

element data/patient/date-of-injury
diagram xfs-cis_diagrams/xfs-cis_p84.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
pattern [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9] 
annotation
documentation
Date of Injury
documentation
This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/job-title
diagram xfs-cis_diagrams/xfs-cis_p85.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 45 
pattern [ -~]* 
annotation
documentation
Patient's Job Title

element data/patient/work-activities
diagram xfs-cis_diagrams/xfs-cis_p86.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 200 
pattern [ -~]* 
annotation
documentation
Patient's Work Activities

element data/patient/patient-working
diagram xfs-cis_diagrams/xfs-cis_p87.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Patient Working Flag

element data/patient/patient-account-no
diagram xfs-cis_diagrams/xfs-cis_p88.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 15 
pattern [ -~]* 
annotation
documentation
Patient's Account No.

element data/employer
diagram xfs-cis_diagrams/xfs-cis_p89.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:name1 c4narr_1012:name2 c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone
annotation
documentation
Employer Information

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p90.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:profession c4narr_1012:wcb-authorization-number c4narr_1012:wcb-rating-code c4narr_1012:nys-license-number c4narr_1012:npi-number c4narr_1012:federal-id-number c4narr_1012:office-location c4narr_1012:billing-address
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p91.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
c4narr_1012:valuederived by: wcb:NonNegativeIntegerrequired      
annotation
documentation
Profession Indicator
documentation
Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

attribute data/doctor/profession/@value
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:NonNegativeInteger
properties
isRef 0
use required
facets
Kind Value annotation 
minInclusive 
maxInclusive 

element data/doctor/wcb-authorization-number
diagram xfs-cis_diagrams/xfs-cis_p92.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:WCBAuthorizationNumber
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]? 
annotation
documentation
WCB Authorization Number
documentation
Provider's WCB Authorization Number.  This field is required for WCB-authorized providers.

One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/wcb-rating-code
diagram xfs-cis_diagrams/xfs-cis_p93.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc unbounded
content simple
facets
Kind Value annotation 
minLength 
maxLength 15 
pattern [ -`{-~]* 
annotation
documentation
WCB Rating Code(s)
documentation
This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for unauthorized providers.

element data/doctor/nys-license-number
diagram xfs-cis_diagrams/xfs-cis_p94.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:NYSLicenseNumber
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
New York State License Number
documentation
Provider's New York State License Number.  This field is required for New York State providers that are not WCB-authorized.

One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/npi-number
diagram xfs-cis_diagrams/xfs-cis_p95.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:NPINumber
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
National Provider Identifier
documentation
Provider's National Provider Identifier.  This element is required for providers outside of New York State.  It should always be populated when the data is available.

One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/federal-id-number
diagram xfs-cis_diagrams/xfs-cis_p96.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type extension of wcb:SSN
properties
isRef 0
content complex
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
attributes
Name  Type  Use  Default  Fixed  annotation
c4narr_1012:typederived by: wcb:NonNegativeIntegerrequired      
annotation
documentation
Federal ID Number
documentation
Set the 'type' attribute as follows:  1=SSN;  2=EIN

attribute data/doctor/federal-id-number/@type
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:NonNegativeInteger
properties
isRef 0
use required
facets
Kind Value annotation 
minInclusive 
maxInclusive 

element data/doctor/office-location
diagram xfs-cis_diagrams/xfs-cis_p97.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p98.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:name1 c4narr_1012:name2 c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country c4narr_1012:telephone
annotation
documentation
Billing Address Information
documentation
If billing inquires need to be sent to an entity other than the doctor, utilize the addr1 element for that name and addr2 for the address.

The next version of the this schema will include discrete elements for billing name.

element data/billing-information
diagram xfs-cis_diagrams/xfs-cis_p99.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:carrier c4narr_1012:diagnosis c4narr_1012:procedure c4narr_1012:wcb-ppo
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p100.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
minOcc 0
maxOcc 1
content complex
children c4narr_1012:wcb-carrier-id c4narr_1012:name1 c4narr_1012:name2 c4narr_1012:addr1 c4narr_1012:addr2 c4narr_1012:city c4narr_1012:state c4narr_1012:zip c4narr_1012:country
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p101.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern W[0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
WCB Carrier ID Code

element data/billing-information/diagnosis
diagram xfs-cis_diagrams/xfs-cis_p102.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
minOcc 1
maxOcc 4
content complex
children c4narr_1012:diagnosis-code c4narr_1012:diagnosis-desc
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p103.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:TextUpperCase
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p104.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 75 
pattern [ -~]* 
annotation
documentation
ICD9 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p105.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
minOcc 1
maxOcc unbounded
content complex
children c4narr_1012:service-from-date c4narr_1012:service-thru-date c4narr_1012:place-of-service c4narr_1012:procedure-code c4narr_1012:procedure-modifier-a c4narr_1012:procedure-modifier-b c4narr_1012:service-diagnosis-code c4narr_1012:service-charge-amount c4narr_1012:service-days-or-units c4narr_1012:service-cob c4narr_1012:service-zip-code
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p106.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p107.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Procedure Dates of Service (end of date range)
documentation
Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service
diagram xfs-cis_diagrams/xfs-cis_p108.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p109.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:TextUpperCase
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p110.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p111.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p112.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
pattern 1?2?3?4? 
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p113.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Decimal
properties
isRef 0
content simple
facets
Kind Value annotation 
minInclusive 0.00 
totalDigits 
fractionDigits 
annotation
documentation
Charge Amount
documentation
Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units
diagram xfs-cis_diagrams/xfs-cis_p114.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p115.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p116.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p117.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Flag
properties
isRef 0
minOcc 0
maxOcc 1
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Preferred Provider Organization Flag

element data/opinion
diagram xfs-cis_diagrams/xfs-cis_p118.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:competent-producing-cause c4narr_1012:history-consistent-complaint c4narr_1012:history-consistent-findings c4narr_1012:percent-temp-impairment
annotation
documentation
Doctor's Opinion

element data/opinion/competent-producing-cause
diagram xfs-cis_diagrams/xfs-cis_p119.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Competent Producing Cause Flag
documentation
Indicates whether or not the occurrence or occupational history described in prior elements (or in a previous report which gave this information) is the competent producing cause of the injury or disease and disability (if any) sustained.

element data/opinion/history-consistent-complaint
diagram xfs-cis_diagrams/xfs-cis_p120.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
History Consistent With Complaint Flag
documentation
Indicates whether or not the patient's complaints are consistent with the history of the injury/illness.

element data/opinion/history-consistent-findings
diagram xfs-cis_diagrams/xfs-cis_p121.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:FlagUnknown
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y', 'N', or 'U'.
annotation
documentation
History Consistent With Findings Flag
documentation
Indicates whether or not the patient's history of the injury/illness is consistent with the doctor's objective findings.

element data/opinion/percent-temp-impairment
diagram xfs-cis_diagrams/xfs-cis_p122.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Decimal
properties
isRef 0
content simple
facets
Kind Value annotation 
minInclusive 0.00 
maxInclusive 100.00 
totalDigits 
fractionDigits 
annotation
documentation
Percentage of Temporary Impairment

element data/authorized-doctor
diagram xfs-cis_diagrams/xfs-cis_p123.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
content complex
children c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:specialty c4narr_1012:provided-services c4narr_1012:supervised-health-care-provider
annotation
documentation
Authorized Doctor
documentation
Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services
diagram xfs-cis_diagrams/xfs-cis_p124.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Provided Services Flag
documentation
Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/authorized-doctor/supervised-health-care-provider
diagram xfs-cis_diagrams/xfs-cis_p125.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
isRef 0
minOcc 0
maxOcc 1
content complex
children c4narr_1012:last-name c4narr_1012:first-name c4narr_1012:middle-initial c4narr_1012:specialty
annotation
documentation
Supervised Health Care Provider
documentation
This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document
diagram xfs-cis_diagrams/xfs-cis_p126.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
properties
content complex
children c4narr_1012:data wcb:attachment-text wcb:attachment-binary
attributes
Name  Type  Use  Default  Fixed  annotation
bp-document-idrequired      
documentation
Business Partner's Internal Document ID Attribute
documentation
This is the business partner's 'serial number' for the document.
bp-document-commentoptional      
documentation
Business Partner's Document Comment Attribute
documentation
Optional document comment for business partner's use.
annotation
documentation
C-4NARR Document (December 2010)

element first-name
diagram xfs-cis_diagrams/xfs-cis_p127.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Name

element last-name
diagram xfs-cis_diagrams/xfs-cis_p128.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of xs:string
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [A-Za-z][ -~]* 
annotation
documentation
Last Name
documentation
First character must be alpahbetic.

element middle-initial
diagram xfs-cis_diagrams/xfs-cis_p129.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Middle Initial

element name
diagram xfs-cis_diagrams/xfs-cis_p130.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Name

element name1
diagram xfs-cis_diagrams/xfs-cis_p131.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Line of Name

element name2
diagram xfs-cis_diagrams/xfs-cis_p132.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Second Line of Name

element specialty
diagram xfs-cis_diagrams/xfs-cis_p133.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Specialty

element state
diagram xfs-cis_diagrams/xfs-cis_p134.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:StringUpperCase
properties
content simple
facets
Kind Value annotation 
length 
pattern [ -`{-~]* 
annotation
documentation
State
documentation
Required if country is USA.

element telephone
diagram xfs-cis_diagrams/xfs-cis_p135.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Telephone Number
documentation
Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip
diagram xfs-cis_diagrams/xfs-cis_p136.png
namespace http://www.wcb.state.ny.us/xml/ns/c4narr_1012
type restriction of wcb:TextUpperCase
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Zip Code
documentation
Required if country is USA or Canada.

element addr1
diagram xfs-cis_diagrams/xfs-cis_p137.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p138.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p139.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 20 
pattern [ -~]* 
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p140.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:StringUpperCase
properties
content simple
facets
Kind Value annotation 
length 
pattern [ -`{-~]* 
annotation
documentation
3-character Country Code
documentation
Required if the associated Zip field is blank.  Element optional if country is USA.

element data
diagram xfs-cis_diagrams/xfs-cis_p141.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
content complex
children c4amr_0908:patient c4amr_0908:doctor c4amr_0908:billing-information c4amr_0908:authorized-doctor
attributes
Name  Type  Use  Default  Fixed  annotation
form-idrequired    C-4AMR  
documentation
Form ID Attribute
documentation
Value is fixed at 'C-4AMR' for this document type.
version-numberrequired    0908  
documentation
Version Number Attribute
documentation
Value is fixed at '0908' for this document type.
source-coderequired    X  
documentation
Source Code Attribute
documentation
Value is fixed at 'X' for XML Forms Submission.
maintenance-type-coderequired    050  
documentation
Maintenance Type Code (ANSI)
documentation
Value is fixed at '050' which is the ANSI code for 'original form'.
annotation
documentation
C-4AMR Discrete Data Elements (August 2009)

element data/patient
diagram xfs-cis_diagrams/xfs-cis_p142.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
children c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country c4amr_0908:telephone c4amr_0908:wcb-case-number c4amr_0908:carrier-case-number c4amr_0908:date-of-birth c4amr_0908:ssn c4amr_0908:date-of-injury c4amr_0908:patient-account-no
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p143.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type cis:CaseID
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
WCB Case ID

element data/patient/carrier-case-number
diagram xfs-cis_diagrams/xfs-cis_p144.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
pattern [ -~]* 
annotation
documentation
Insurance Carrier's Case ID

element data/patient/date-of-birth
diagram xfs-cis_diagrams/xfs-cis_p145.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p146.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:SSN
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
Patient's Social Security Number

element data/patient/date-of-injury
diagram xfs-cis_diagrams/xfs-cis_p147.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
pattern [1-2][0-9][0-9][0-9]-[0-9][0-9]-[0-9][0-9] 
annotation
documentation
Date of Injury
documentation
This element does not need to be a complete date.  It must contain at least a valid year <= current year.  Month and day can be 00.  If the month or day is given, they must be a valid combination <= today.  Must be >= Date-of-Birth.

element data/patient/patient-account-no
diagram xfs-cis_diagrams/xfs-cis_p148.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 15 
pattern [ -~]* 
annotation
documentation
Patient's Account No.

element data/doctor
diagram xfs-cis_diagrams/xfs-cis_p149.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
children c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:profession c4amr_0908:wcb-authorization-number c4amr_0908:wcb-rating-code c4amr_0908:nys-license-number c4amr_0908:npi-number c4amr_0908:federal-id-number c4amr_0908:office-location c4amr_0908:billing-address c4amr_0908:referring-doctor
annotation
documentation
Doctor's Information

element data/doctor/profession
diagram xfs-cis_diagrams/xfs-cis_p150.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
c4amr_0908:valuederived by: wcb:NonNegativeIntegerrequired      
annotation
documentation
Profession Indicator
documentation
Set 'value' attribute as follows:  1=Physician;  2=Podiatrist;  3=Chiropractor

attribute data/doctor/profession/@value
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:NonNegativeInteger
properties
isRef 0
use required
facets
Kind Value annotation 
minInclusive 
maxInclusive 

element data/doctor/wcb-authorization-number
diagram xfs-cis_diagrams/xfs-cis_p151.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:WCBAuthorizationNumber
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9CPL][0-9][0-9][0-9][0-9][0-9]-[0-9][IBW]? 
annotation
documentation
WCB Authorization Number
documentation
Provider's WCB Authorization Number.  This field is required for WCB-authorized providers.

One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/wcb-rating-code
diagram xfs-cis_diagrams/xfs-cis_p152.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc unbounded
content simple
facets
Kind Value annotation 
minLength 
maxLength 15 
pattern [ -`{-~]* 
annotation
documentation
WCB Rating Code(s)
documentation
This element is required for WCB-authorized providers.  Include all rating codes for the provider.  Each code must be a valid WCB Rating Code.  This element should not be populated for unauthorized providers.

element data/doctor/nys-license-number
diagram xfs-cis_diagrams/xfs-cis_p153.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:NYSLicenseNumber
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
New York State License Number
documentation
Provider's New York State License Number.  This field is required for New York State providers that are not WCB-authorized.

One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/npi-number
diagram xfs-cis_diagrams/xfs-cis_p154.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:NPINumber
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
National Provider Identifier
documentation
Provider's National Provider Identifier.  This element is required for providers outside of New York State.  It should always be populated when the data is available.

One of the wcb-authorization-number, nys-license-number, and npi-number elements must be populated.

element data/doctor/federal-id-number
diagram xfs-cis_diagrams/xfs-cis_p155.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type extension of wcb:SSN
properties
isRef 0
content complex
facets
Kind Value annotation 
pattern [0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
attributes
Name  Type  Use  Default  Fixed  annotation
c4amr_0908:typederived by: wcb:NonNegativeIntegerrequired      
annotation
documentation
Federal ID Number
documentation
Set the 'type' attribute as follows:  1=SSN;  2=EIN

attribute data/doctor/federal-id-number/@type
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:NonNegativeInteger
properties
isRef 0
use required
facets
Kind Value annotation 
minInclusive 
maxInclusive 

element data/doctor/office-location
diagram xfs-cis_diagrams/xfs-cis_p156.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
children c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country c4amr_0908:telephone
annotation
documentation
Office Location Information

element data/doctor/billing-address
diagram xfs-cis_diagrams/xfs-cis_p157.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
children c4amr_0908:name1 c4amr_0908:name2 c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country c4amr_0908:telephone
annotation
documentation
Billing Address Information
documentation
If billing inquires should be made to an entity other than the doctor, utilize the optional elements name1 and name2 to identify the name of that entity and use the address elements to specify that entity's address.

Otherwise, it is only necessary to populate the address elements with the doctor's address.

element data/doctor/referring-doctor
diagram xfs-cis_diagrams/xfs-cis_p158.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
children c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial
annotation
documentation
Referring Doctor's Name

element data/billing-information
diagram xfs-cis_diagrams/xfs-cis_p159.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
children c4amr_0908:carrier c4amr_0908:diagnosis c4amr_0908:procedure c4amr_0908:wcb-ppo
annotation
documentation
Billing Information

element data/billing-information/carrier
diagram xfs-cis_diagrams/xfs-cis_p160.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
minOcc 0
maxOcc 1
content complex
children c4amr_0908:wcb-carrier-id c4amr_0908:name1 c4amr_0908:name2 c4amr_0908:addr1 c4amr_0908:addr2 c4amr_0908:city c4amr_0908:state c4amr_0908:zip c4amr_0908:country
annotation
documentation
Insurance Carrier Information

element data/billing-information/carrier/wcb-carrier-id
diagram xfs-cis_diagrams/xfs-cis_p161.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of xs:string
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern W[0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
WCB Carrier ID Code

element data/billing-information/diagnosis
diagram xfs-cis_diagrams/xfs-cis_p162.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
minOcc 1
maxOcc 4
content complex
children c4amr_0908:diagnosis-code c4amr_0908:diagnosis-desc
annotation
documentation
Diagnosis Information

element data/billing-information/diagnosis/diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p163.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:TextUpperCase
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
ICD9 Diagnosis Code

element data/billing-information/diagnosis/diagnosis-desc
diagram xfs-cis_diagrams/xfs-cis_p164.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 75 
pattern [ -~]* 
annotation
documentation
ICD9 Diagnosis Description

element data/billing-information/procedure
diagram xfs-cis_diagrams/xfs-cis_p165.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
minOcc 1
maxOcc unbounded
content complex
children c4amr_0908:service-from-date c4amr_0908:service-thru-date c4amr_0908:place-of-service c4amr_0908:procedure-code c4amr_0908:procedure-modifier-a c4amr_0908:procedure-modifier-b c4amr_0908:service-diagnosis-code c4amr_0908:service-charge-amount c4amr_0908:service-days-or-units c4amr_0908:service-cob c4amr_0908:service-zip-code
annotation
documentation
Medical Procedure Information

element data/billing-information/procedure/service-from-date
diagram xfs-cis_diagrams/xfs-cis_p166.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Procedure Dates of Service (start of date range)
documentation
Must be >= injury-date.

element data/billing-information/procedure/service-thru-date
diagram xfs-cis_diagrams/xfs-cis_p167.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Procedure Dates of Service (end of date range)
documentation
Must be >= service-from-date and <= current date.

element data/billing-information/procedure/place-of-service
diagram xfs-cis_diagrams/xfs-cis_p168.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Place of Service

element data/billing-information/procedure/procedure-code
diagram xfs-cis_diagrams/xfs-cis_p169.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:TextUpperCase
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Code

element data/billing-information/procedure/procedure-modifier-a
diagram xfs-cis_diagrams/xfs-cis_p170.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Modifier A

element data/billing-information/procedure/procedure-modifier-b
diagram xfs-cis_diagrams/xfs-cis_p171.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:TextUpperCase
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Procedure Modifier B

element data/billing-information/procedure/service-diagnosis-code
diagram xfs-cis_diagrams/xfs-cis_p172.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of xs:string
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
pattern 1?2?3?4? 
annotation
documentation
Diagnosis Code

element data/billing-information/procedure/service-charge-amount
diagram xfs-cis_diagrams/xfs-cis_p173.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Decimal
properties
isRef 0
content simple
facets
Kind Value annotation 
minInclusive 0.00 
totalDigits 
fractionDigits 
annotation
documentation
Charge Amount
documentation
Must be >= $0.00.

element data/billing-information/procedure/service-days-or-units
diagram xfs-cis_diagrams/xfs-cis_p174.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Days or Units

element data/billing-information/procedure/service-cob
diagram xfs-cis_diagrams/xfs-cis_p175.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
COB

element data/billing-information/procedure/service-zip-code
diagram xfs-cis_diagrams/xfs-cis_p176.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
isRef 0
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Zip Code where service was rendered

element data/billing-information/wcb-ppo
diagram xfs-cis_diagrams/xfs-cis_p177.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:Flag
properties
isRef 0
minOcc 0
maxOcc 1
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Preferred Provider Organization Flag

element data/authorized-doctor
diagram xfs-cis_diagrams/xfs-cis_p178.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
content complex
children c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:specialty c4amr_0908:provided-services c4amr_0908:supervised-health-care-provider
annotation
documentation
Authorized Doctor
documentation
Putting doctor's name here is equivalent to signing the paper C-4.

element data/authorized-doctor/provided-services
diagram xfs-cis_diagrams/xfs-cis_p179.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type wcb:Flag
properties
isRef 0
content complex
attributes
Name  Type  Use  Default  Fixed  annotation
wcb:valuederived by: wcb:Stringrequired      
documentation
Value must be 'Y' or 'N'.
annotation
documentation
Provided Services Flag
documentation
Set 'value' attribute as follows:  'Y' if the WCB Authorized Doctor provided the services, or 'N' if the WCB Authorized Doctor actively supervised another health care provider who provided these services.

element data/authorized-doctor/supervised-health-care-provider
diagram xfs-cis_diagrams/xfs-cis_p180.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
isRef 0
minOcc 0
maxOcc 1
content complex
children c4amr_0908:last-name c4amr_0908:first-name c4amr_0908:middle-initial c4amr_0908:specialty
annotation
documentation
Supervised Health Care Provider
documentation
This element and ALL of its child elements (last-name, first-name, and specialty) are required when the 'value' attribute of the provided-services element (child of authorized-doctor element) is 'N'.

element document
diagram xfs-cis_diagrams/xfs-cis_p181.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
properties
content complex
children c4amr_0908:data wcb:attachment-text wcb:attachment-binary
attributes
Name  Type  Use  Default  Fixed  annotation
bp-document-idrequired      
documentation
Business Partner's Internal Document ID Attribute
documentation
This is the business partner's 'serial number' for the document.
bp-document-commentoptional      
documentation
Business Partner's Document Comment Attribute
documentation
Optional document comment for business partner's use.
annotation
documentation
C-4AMR Document (August 2009)

element first-name
diagram xfs-cis_diagrams/xfs-cis_p182.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Name

element last-name
diagram xfs-cis_diagrams/xfs-cis_p183.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of xs:string
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [A-Za-z][ -~]* 
annotation
documentation
Last Name
documentation
First character must be alpahbetic.

element middle-initial
diagram xfs-cis_diagrams/xfs-cis_p184.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -~]* 
annotation
documentation
Middle Initial

element name
diagram xfs-cis_diagrams/xfs-cis_p185.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Name

element name1
diagram xfs-cis_diagrams/xfs-cis_p186.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Line of Name

element name2
diagram xfs-cis_diagrams/xfs-cis_p187.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Second Line of Name

element specialty
diagram xfs-cis_diagrams/xfs-cis_p188.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Specialty

element state
diagram xfs-cis_diagrams/xfs-cis_p189.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:StringUpperCase
properties
content simple
facets
Kind Value annotation 
length 
pattern [ -`{-~]* 
annotation
documentation
State
documentation
Required if country is USA.

element telephone
diagram xfs-cis_diagrams/xfs-cis_p190.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Telephone Number
documentation
Use appropriate formatting:  (xxx)xxx-xxxx ext xxx

element zip
diagram xfs-cis_diagrams/xfs-cis_p191.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_0908
type restriction of wcb:TextUpperCase
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 
pattern [ -`{-~]* 
annotation
documentation
Zip Code
documentation
Required if country is USA or Canada.

element addr1
diagram xfs-cis_diagrams/xfs-cis_p192.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
First Line of Street Address

element addr2
diagram xfs-cis_diagrams/xfs-cis_p193.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 30 
pattern [ -~]* 
annotation
documentation
Second Line of Street Address

element city
diagram xfs-cis_diagrams/xfs-cis_p194.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type restriction of wcb:Text
properties
content simple
facets
Kind Value annotation 
minLength 
maxLength 20 
pattern [ -~]* 
annotation
documentation
City

element country
diagram xfs-cis_diagrams/xfs-cis_p195.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type restriction of wcb:StringUpperCase
properties
content simple
facets
Kind Value annotation 
length 
pattern [ -`{-~]* 
annotation
documentation
3-character Country Code
documentation
Required if the associated Zip field is blank.  Element optional if country is USA.

element data
diagram xfs-cis_diagrams/xfs-cis_p196.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties
content complex
children c4amr_1012:patient c4amr_1012:doctor c4amr_1012:billing-information c4amr_1012:authorized-doctor
attributes
Name  Type  Use  Default  Fixed  annotation
form-idrequired    C-4AMR  
documentation
Form ID Attribute
documentation
Value is fixed at 'C-4AMR' for this document type.
version-numberrequired    1012  
documentation
Version Number Attribute
documentation
Value is fixed at '1012' for this document type.
source-coderequired    X  
documentation
Source Code Attribute
documentation
Value is fixed at 'X' for XML Forms Submission.
maintenance-type-coderequired    050  
documentation
Maintenance Type Code (ANSI)
documentation
Value is fixed at '050' which is the ANSI code for 'original form'.
annotation
documentation
C-4AMR Discrete Data Elements (December 2010)

element data/patient
diagram xfs-cis_diagrams/xfs-cis_p197.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
properties
isRef 0
content complex
children c4amr_1012:last-name c4amr_1012:first-name c4amr_1012:middle-initial c4amr_1012:addr1 c4amr_1012:addr2 c4amr_1012:city c4amr_1012:state c4amr_1012:zip c4amr_1012:country c4amr_1012:telephone c4amr_1012:wcb-case-number c4amr_1012:carrier-case-number c4amr_1012:date-of-birth c4amr_1012:ssn c4amr_1012:date-of-injury c4amr_1012:patient-account-no
annotation
documentation
Patient Information

element data/patient/wcb-case-number
diagram xfs-cis_diagrams/xfs-cis_p198.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type cis:CaseID
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
pattern [ADF-HJ-NP-Z0-9][A-HJ-NP-Z0-9][0-9][0-9][0-9][0-9][0-9][0-9] 
annotation
documentation
WCB Case ID

element data/patient/carrier-case-number
diagram xfs-cis_diagrams/xfs-cis_p199.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type restriction of wcb:Text
properties
isRef 0
minOcc 0
maxOcc 1
content simple
facets
Kind Value annotation 
minLength 
maxLength 25 
pattern [ -~]* 
annotation
documentation
Insurance Carrier's Case ID

element data/patient/date-of-birth
diagram xfs-cis_diagrams/xfs-cis_p200.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type wcb:Date
properties
isRef 0
content simple
annotation
documentation
Patient's Date of Birth
documentation
Must be <= Accident-Date.

element data/patient/ssn
diagram xfs-cis_diagrams/xfs-cis_p201.png
namespace http://www.wcb.state.ny.us/xml/ns/c4amr_1012
type wcb:SSN
properties
isRef 0
minOcc