New York State
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
20 Park Street Albany, New York 12207
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
20 Park Street Albany, New York 12207
Andrew M. Cuomo
Governor
Subject No. 046-1.15
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
| 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 |
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