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New York State
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
20 Park Street   Albany, New York 12207
Andrew M. Cuomo
Governor



Subject No. 046-1.15

New And Revised Workers' Compensation Board Forms

9-1-09 through 12-31-10

Date: January 18, 2011

The table below shows Workers' Compensation Board forms that have been recently issued or revised. Most of these forms are available on the Board's website (www.wcb.ny.gov) under the heading Forms. For information on any Board form, contact the Board's Forms Department at FormsDepartment@wcb.ny.gov.

Forms Department

 

Recently Issued or Revised Workers' Compensation Board Forms
9-1-09 through 12-31-10
FORM NO. TITLE DATE
AFF-1 Affidavit for Death Benefits 12-10
AFF-2 OBSOLETE – Use AFF-1 in all circumstances.
AFF-3 OBSOLETE – Use AFF-1 in all circumstances.
C-3 Employee Claim 11-10
C-3S Reclamación del Empleado (Spanish version of Form C-3) 11-10
C-3.3 Limited Release of Health Information (HIPAA) 12-09
C-4 Doctor's Initial Report 12-10
C-4 AMR Ancillary Medical Report 12-10
C-4 AUTH Attending Doctor's Request for Authorization and Carrier's Response 12-10
C-4.2 Doctor's Progress Report 12-10
C-5 Attending Ophthalmologist's Report 12-10
C-8.1 Notice of Treatment Issue/Disputed Bill 12-10
C-8.4 Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (or a Portion of) a Medical Bill Due to Valuation Objection(s) 12-10
C-32 Settlement Agreement, Section 32 11-09
C-32.1 Section 32 Settlement Agreement: Claimant Release 6-10
C-105.11 Consent to NYS Workers' Compensation Board Jurisdiction for non-New York Licensed Carriers (3C Coverage) 11-10
C-257 Claimant's Record of Medical and Travel Expenses and Request for Reimbursement 9-10
C-258 Claimant's Record of Job Search Efforts/Contacts 8-10
C-312.5 Agreed Upon Findings and Awards For Proposed Conciliation Decision (Represented Claimants Only) 12-10
DB-120 Notice of Compliance – Disability Benefits Law 6-10
MD-1 Attending Doctor's Request for Medical Authorization Determination 12-09
MD-3 Carrier/Board-Approved Self-Insured Employer's Objection to Attending Doctor's Request for Medical Authorization Determination 12-09
MG-1 Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response 12-10
MG-1.1 Continuation to Form MG-1, Attending Doctor's Request for Optional Prior Approval 12-10
MG-2 Attending Doctor's Request for Approval of Variance and Carrier's Response 12-10
MG-2.1 Continuation to Form MG-2, Attending Doctor's Request for Approval of Variance 12-10
MR-4 Impartial Specialist's Report of Medical Records Review 12-10
OC-110A Claimant's Authorization to Disclose Workers' Compensation Records (WCL Section 110-a) 12-09
OC-110AORD Request for Judicial Order – Access to Case Files 7-10
OT/PT-4 Occupational/ Physical Therapist's Report 12-10
PS-4 Psychologist's Report 12-10
RB-89 Cover Sheet – Application for Board Review 6-10
RB-89.1 Cover Sheet – Rebuttal of Application for Board Review 6-10
RB-89.2 Cover Sheet – Application for Reconsideration / Full Board Review 6-10
RB-89.3 Cover Sheet – Rebuttal of Application for Reconsideration / Full Board Review 6-10
RFA-1LC Request for Further Action by Legal Counsel 12-10
RFA-1W Request for Assistance by Injured Worker 12-10
RFA-1 OBSOLETE – Attorney/Representative should use RFA-1LC. Injured Worker should use RFA-1W
RFA-2 Carrier's/Employer's Request for Further Action 12-10
W-32R WAMO Settlement Agreement-Section 32 11-09
WTC-12 Registration of Participation in World Trade Center Rescue, Recovery and/or Cleanup Operations: Sworn Statement Pursuant to WCL §162 12-09