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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Subject No. 046-109

To:  Authorized Health Care Providers; Licensed Physical and Occupational Therapists; Insurance Carriers and Self-Insured Employers Providing Benefits Under the Workers' Compensation Law, Volunteer Firefighters' Benefit Law and the Volunteer Ambulance Workers' Benefit Law; Third Party Administrators; Attorneys and Licensed Representatives Appearing Before the Board

New Form FCE-4, Practitioner's Report of Functional Capacity Evaluation

Date:  Friday, November 8, 2002

Attached is a copy of new Form FCE-4, Practitioner's Report of Functional Capacity Evaluation. New Form FCE-4 is to be completed by physical or occupational therapists currently holding a valid license in New York State, or other licensed provider qualified by scope of practice. A Functional Capacity Evaluation (FCE) may be made at the request of either the insurance carrier/employer or the claimant's attending physician. Prior authorization by the carrier is not required. The FCE, when medically necessary and indicated, may be performed only at the point of maximum medical improvement in the opinion of the attending physician.

A Functional Capacity Evaluation is utilized for the following purposes:

  1. To determine the level of safe maximal function at the time of maximum medical improvement.
  2. To provide a pre-vocational baseline of functional capabilities to assist in the vocational rehabilitation process.
  3. To objectively set restrictions and guidelines for return to work.
  4. To determine whether specific job tasks can be safely performed by modification of technique, equipment, or by further training.
  5. To determine whether additional treatment or referral to a work hardening program is indicated.
  6. To assess outcome at the conclusion of a work hardening program.

See the reverse of Form FCE-4 for a list of the indications and requirements for Functional Capacity Evaluations as contained in the NY Workers' Compensation Medicine Fee Schedule.

New Form FCE-4 is effective immediately. Any questions or concerns regarding this new form may be directed to the attention of Mr. Joseph Salamone, Director of Health Provider Administration, (518) 486-3313. Health care providers, practitioners, carriers and self-insured employers are authorized to reproduce this form in quantity according to their needs. Form FCE-4 is to be printed on 8 ½" x 11" 20lb. white bond, two-sides, head to head. The prescribed text, format and size must be followed in all respects. Additional copies of the form may be obtained at the Board's web site


Robert R. Snashall


View Form FCE-4 (10/02) adobe pdf