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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Subject Number 046-155

Please do not send requests for forms to William Bryant. As of July 2007 all requests should be sent to the attention of the "Reproduction Unit".



April 25, 2006

As part of the Board's efforts to improve the process related to medical providers' requests for authorization for special medical services costing more than $500.00, Forms C-669, Notice to Chair of Carrier's Action on Claim for Benefits, and C-7, Notice That Right to Compensation is Controverted, have been modified to include an item in which the carrier/self-insured employer must provide the name and telephone number of the employee designated in accordance with NYCRR 325-1.4(4) to receive and act upon such requests.

NYCRR 325-1.4(4)
In order to process such requests expeditiously and within the time limits specified hereunder, the insurance carrier shall designate a qualified employee in its office, and the self- insured employer shall designate a qualified employee in its office or an authorized employee of its licensed representative, to receive and act upon such requests.

The new items are #19 on Form C-7 and #17 on Form C-669.


In addition to the changes noted above, Form C-7 has also been revised to include a new item (#17) asking if the alleged injury was the result of the use or operation of a motor vehicle, and if so the name and address of the No-Fault carrier. This information is needed in order to hold an expedited hearing, if necessary, in accordance with Section 142(7) WCL, which provides as follows:

Where there has been a motor vehicle accident which caused personal injury and there is a dispute as to whether the injury occurred in the course of employment, the worker's compensation board shall, after notice to the no fault carrier and the workers' compensation carrier, hold an expedited hearing on the issue of whether the accident occurred during the course of employment.

We ask carriers' and self-insurers' cooperation in including the information requested in these new items in all C-7 and C-669 reports filed with the Board. Also, please remember to file these forms with the claimant, his/her representative, if any, and with all health providers treating the claimant, at the same time they are filed with the Board.

Revised Forms C-7 and C-669 are effective immediately. Master copies may be obtained by downloading the specific pdf file copy from the Board's web site ( under the heading Common Forms, or by writing or faxing the Board at:

NYS Workers' Compensation Board - Attn: Mr. William Bryant
100 Broadway-Menands, Albany, NY 12241
FAX: (518) 486-3515