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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. 046-444

New and Revised Forms For Medical Treatment Guidelines

Date: October 21, 2010

As part of the establishment of standardized Medical Treatment Guidelines for the treatment of the Neck, Shoulder, Mid and Low Back, and Knee (see Subject No. 046-445 for more information and training opportunities), the Board has developed new forms and revised existing forms to implement this major change

The Medical Treatment Guidelines and these new and revised forms are effective for medical services rendered on or after December 1, 2010. Sample forms are now available on the Board’s website so users can become familiar with them and update their systems accordingly. They are not to be filed before December 1, 2010 or used with respect to services rendered before that date. At that time, usable forms will be posted on the Board’s regular form pages. Here is a link to the sample forms:

The new forms are:

  • MG-1, Attending Doctor’s Request for Optional Prior Approval and Carrier’s/Employer’s Response
  • MG-1.1, Continuation to Form MG-1, Attending Doctor’s Request for Optional Prior Approval
  • MG-2, Attending Doctor’s Request for Approval of Variance and Carrier’s/Employer’s Response
  • MG-2.1, Continuation to Form MG-2, Attending Doctor’s Request for Approval of Variance

The revised forms are:

  • C-4, Doctor’s Initial Report
  • C-4.2, Doctor’s Progress Report
  • C-4 AMR, Ancillary Medical Report
  • C-4 AUTH, Attending Doctor’s Request for Authorization and Carrier’s Response
  • C-5, Attending Ophthalmologist’s Report
  • EC-4 NARR, Doctor’s Narrative Report
  • C-8.1, Notice of Treatment Issue/Disputed Bill
  • OT/PT-4, Occupational/Physical Therapist’s Report
  • PS-4, Attending Psychologist’s Report

The instructions for requesting authorization for special services on these forms have been revised to indicate that certain services, regardless of cost, require pre-authorization pursuant to the new Medical Treatment Guidelines. Part B of Form C-8.1 has been revised to include a section for carrier objections due to non-compliance with the Guidelines.

In addition to the changes for Medical Treatment Guidelines, the most significant change in the revised medical reports is that they reflect an upcoming amendment to Board regulations regarding medical reporting requirements. The new regulations, which are effective for services rendered on or after December 1, 2010, provide for filing of medical reports as follows:

  1. within 48 hours following first treatment;
  2. within 15 days after filing the medical report filed within 48-hours after the first treatment;
  3. thereafter, a progress report whenever a follow-up visit is necessary, provided the interval between medical reports shall be no more than 90 days; and
  4. when a claimant reaches maximum medical improvement, which must include an opinion whether or not there is any permanent impairment.

Please note that these revised reporting requirements apply to dates of service on or after December 1, 2010. Until that date, the current reporting requirements remain in effect and must be observed.

Thank you for your cooperation.


Robert E. Beloten