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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. 046-345

Revised Medical Report Forms August 2009

Date: August 28, 2009

This release is to announce revisions to the new C-4 family of forms. The new version dates are:

Form C-4 (8-09), Doctor's Initial Report

Form C-4.2 (8-09), Doctor's Progress Report

Form C-4.3 (8-09), Doctor's Report of MMI/Permanent Impairment

Form C-4 AMR (8-09), Ancillary Medical Report

Form C-4 AUTH (8-09), Attending Doctor's Request for Authorization and Carrier's Response

Forms C-4, C-4.2 and C-4.3 were revised to include an item in the Doctor's Information section for the Billing Group or Practice Name. This was requested by many carriers to facilitate proper payment. The item for NPI# was revised to specify Treating Doctor's NPI#. References to the "pre-authorized procedures list" were removed from all forms pending finalization of that list. On Forms C-4 and C-4.2, the text referencing the use of the C-4 AUTH form was modified slightly.

Form C-4 AMR was revised to indicate that the form may be used in place of a regular report by a medical provider who is only giving clearance for surgery. Billing group/practice name had been added to an earlier version of this form.

Form C-4 AUTH was revised to allow the faxing of the authorization request to the insurance carrier/self-insured employer.

All the forms were also revised to include the Board's Statewide Centralized fax number (877-533-0337), which can be used for most claims-related documents, including medical reports (see Subject No. 046-296 for details), and the new address of the Board's Buffalo District Office.

All of the revised forms are available in the Health Care Providers Forms section of the Board's website. Use of the 8-09 versions of these forms is recommended but not mandatory at this time. Current versions of the new C-4 family of forms may continue to be used with existing practice management software. However, as announced in Subject No. 046-301R, the Board will not enforce payment for any examinations, services and/or treatments provided that are not reported using the new C-4 family of forms for services provided on and after April 1, 2009. In addition, the Board will investigate why the doctor is not using the correct form and, if warranted, issue an administrative warning or commence temporary suspension or revocation proceedings.

Thank you for your cooperation.


Robert E. Beloten