Skip to Content

Workers’ Compensation Board

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

Subject No. 046-273

Mandatory Use of Board Prescribed Medical Report Forms
- Extension of Transition Period

Date: December 17, 2008

On September 17, 2008, the Chair announced the implementation of a revised set of core forms (Subject Number 046-250), including changes to the Attending Doctor's Report (C-4) Form and the addition of new medical forms. Form C-4 has been renamed the Doctor's Initial Report and is only completed the first time a doctor treats a claimant for a particular workers' compensation claim. For subsequent visits the Board created Form C-4.2 (Doctor's Progress Report), a shorter version of Form C-4. When a patient reaches maximum medical improvement, doctors will now complete a third form, Form C-4.3 (Doctor's Report of MMI/Permanent Impairment).

Doctors were informed that they should begin using the new forms as soon as possible but by no later than January 1, 2009.

The Board received numerous comments and questions about the new forms. In response to some of the comments the Board further revised the forms. For example, the Board removed the questions about the use of the medical treatment guidelines. The Board will also soon release an additional form, the C-4AMR (Ancillary Medical Report), for providers of ancillary services to report their services. To answer the questions doctors submitted, the Board created a Frequently Asked Questions page on its website regarding the revised and new forms at This page is updated regularly with additional questions and answers.

In addition to submitting them in paper, all of the new C-4 forms can be submitted electronically through the Board's website. The Board has also developed an electronic narrative version of the C-4 and C-4.2 (EC-4NARR) that will be released this month. The EC-4NARR contains significantly fewer questions than Forms C-4 and C-4.2. Doctors must include narrative attachments with the form that will provide all the additional information which otherwise would be on the other forms. Form EC-4NARR will only be accepted by the Board through electronic submission. The Board will accept the EC-4NARR as an equivalent to Forms C-4 and C-4.2 if it includes a narrative attachment and is filed electronically with the Board.

The Board has received numerous requests from doctors to delay the mandatory use of the new C-4 family of forms. Such requests are based upon the doctors' need to familiarize themselves with the changes and to implement them into their office software and/or business practices.

In order to provide doctors with the time necessary to familiarize themselves with the new forms and integrate them into their practices, the Board is extending the transition period until March 31, 2009. Between now and March 31, 2009, doctors will not be penalized if they do not use the new forms. During this period, if a doctor does not use the correct new form, he or she may submit a fully completed old C-4 form, provided he or she attaches the office notes or narratives.

As of April 1, 2009, doctors must use the new forms. Doctors who do not use the new C-4 family of forms on and after April 1, 2009, will be penalized. The Board will not enforce payment for any examinations, services and/or treatments provided that are not reported and billed using the correct new C-4 form. In other words, if the doctor does not submit the correct Board prescribed form, the liable self-insured employer, insurance carrier, third-party administrator, Re-opened Case Fund, or the State Insurance Fund is not required to pay the doctor for any examinations, services and/or treatments included in the documentation submitted. In addition, the Board will investigate why the doctor is not using the correct new form and if warranted issue an administrative warning or commence temporary suspension or revocation proceedings.

Any questions regarding these matters should be referred to the Office of General Counsel at 518-486-9564.


Zachary S. Weiss