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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor David A. Paterson

Subject No. 046-250

Core Board Forms Revised

Date: September 17, 2008


One of the goals of the Workers' Compensation Reform initiative is to enhance the service the Board provides to injured workers, employers and stakeholders. A critical element of this effort is the redesign of forms the Board uses to gather information about a claim. The goals of the forms redesign effort were to develop more user-friendly forms while collecting additional information needed to more quickly process and resolve claims including claims that have been controverted.

Revised Forms Process

To initiate the revised forms process the Board formed an internal working team and procured a forms expert to design the initial revisions of the forms.

In October and November of 2007 the Board met with representatives from various stakeholder groups representing workers, businesses, medical providers, insurance carriers and attorneys to gather feedback on the initial revisions to the forms.

Between December 11th, 2007 and January 24th 2008, the Board posted the revised C-2, C-3, C-4, and C-4.2 forms on its website for input from the general public. During this period the Board received over 340 survey responses.

In February 2008, the Board contracted with a focus group expert, to design and facilitate a series of focus groups. Between March 3rd and April 10th, 2008, focus groups were held at various locations across the state and feedback was collected.

After each step in the process suggestions were evaluated and changes were incorporated.

In addition, Forms C–2 and C–3 were reviewed with plain language experts to ensure ease of use for all participants in the workers' compensation system.

With the Board's approval of the Streamline Docket regulations the revised forms are now available for use. All parties are to begin using the new forms as soon as possible but by no later than January 1, 2009.

Revised Forms

C–2 – Form C–2 has been renamed the Employer's Report of Work–Related Injury/Illness and requests additional information such as: WCB Policy Period, date the employee gave notice of accident/illness, employee's supervisor and a list of any witnesses. Revised Form C–2 is available for electronic submission to the Board from the website.

C–3 – Form C–3 (Employee Claim) was redesigned for ease of use and requests additional information including date hired, supervisor name, and information regarding previous injuries to the same body part or a previous similar illness. Revised Form C–3 is available for electronic submission to the Board from the website. A claimant can also complete and submit Form C–3 over the phone by calling 1–866–396–8314.

C–3S – Form C–3S is a new form which is a Spanish version of the redesigned Employee Claim form and is available on the Board's website.

C–3.3 – Form C–3.3 is a new form for authorizing the limited release of medical information. This form is to be completed by claimants who have had a previous injury to the same body part or a previous similar illness. Form C–3.3 can be found at the end of Form C–3 and as a separate form on the Board's website.

C–4 – Form C–4 has been renamed the Doctor's Initial Report. This form is to be completed the first time a provider treats a claimant for a particular workers' compensation claim. One item of note is that the request for medical authorization is not included in the new C–4 form; instead new Form C–4AUTH (see below) should be used to request authorization. Revised Form C–4 is available for electronic submission to the Board from the website.

C–4.2 – Form C–4.2 (Doctor's Progress Report) is a new, shorter version of Form C–4 which is to be used for all subsequent visits to report continuing services. Form C–4.2 is available for electronic submission to the Board from the website.

C–4.3 – Form C–4.3 is a new form to be completed once a patient has reached Maximum Medical Improvement and captures the percentage of permanent impairment. Form C–4.3 is available for electronic submission to the Board from the website.

C–4AUTH – Form C–4AUTH (Attending Doctor's Request for Authorization and Carrier's Response) is a new form with which the attending health care provider may request authorization from the carrier for a special medical service costing over $1,000. The carrier will submit its response to the provider on the same C–4AUTH form sent by the provider. This new form allows providers to highlight the special services they feel are medically needed, enables carriers to easily respond to such requests in writing, and enables the Board to track requests and responses to insure that all statutory timeframes are met.

Please visit the Board's website at to obtain or submit a form.


Zachary S. Weiss