Workers' Compensation Forms for Health Care Providers
Forms are in PDF format. The Board recommends using the
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After the form opens in your browser, you may complete the form by typing information on the form before you print it.
IMPORTANT: Two-sided and multi-page forms are to be printed and submitted to the Board in duplex format. If this is not possible, submit as separate sheets. However, do NOT submit to the Board any sheets that contain only instructions and/or reference material. Parties of interest other than the Board must receive both sides of all two-sided forms and all pages of multi-page forms.
If you require assistance with completing these forms, please contact your local WCB District Office.
The New C-4 Family of Forms: Frequently Asked Questions
| Form Number / Version Date |
Form Title | Who Files | Where to File | When to File |
|---|---|---|---|---|
| C-4 (1/11) Paper Version [C-4 On-line Submission] See Subject No. 046-398 — Authorized Provider Shortage in Rochester Area; Temporary Change in Medical Reporting Requirements |
Doctor's Initial Report | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | This form is filed within 48 hours of first treatment. To report continued treatment, use Form C-4.2. To report permanent impairment use Form C-4.3. |
| C-4.2 (1/11) Paper Version [C-4.2 On-line Submission] |
Doctor's Progress Report | Health Care Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | This form is used for the 15 day report after first treatment, and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart. To report the first time you treated claimant use Form C-4. To report permanent impairment use Form C-4.3. |
| EC-4NARR (12/10) On-line Submission |
Doctor's Narrative Report | Health Care Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | Use this form to report first treatment; for the 15 day report after first treatment; and for each follow-up visit scheduled when medically necessary while treatment continues but not more than 90 days apart. To report permanent impairment use Form C-4.3. Use this form only if attaching a detailed narrative report. See Attachment Requirements for topics that must be addressed in the narrative attachment. |
| C-4.3 (1/12) Paper Version [C-4.3 On-line Submission] |
Doctor's Report of MMI/Permanent Impairment | Health Care Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment. |
| C-4 AMR (1/11) Paper Version [EC-4 AMR On-line Submission] |
Ancillary Medical Report | Provider Other than the Attending Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | As soon as possible after ancillary treatment or services (such as radiology, pathology or diagnostic services) are rendered. |
| C-4 AUTH (2-13) |
Attending Doctor's Request for Authorization and Carrier's Response | Health Care Provider | Insurance Carrier/Self-Insured Employer, with a copy to the Workers' Compensation Board. If the patient is represented by an attorney or licensed representative send a copy to such legal representative. If the patient is not represented, a copy must be sent to the patient. | This form is used to confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation. |
| C-4.1 (9/08) | Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4 | Health Provider | See Form C-4. This form must be attached to and filed with Form C-4. (May also be used with Forms C-4.2, C-4.3, C-5, PS-4 and OT/PT-4) | See Form C-4. Use as continuation sheet when more than six dates of service must be shown in the billing portion of Form C-4. (May also be used with Forms C-4.2, C-4.3, C-5, PS-4 and OT/PT-4) |
| C-5 (1/11) | Attending Ophthalmologist's Report | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative. | 48 hour initial report, within 48 hours of first treatment. 15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
| C-27 (1/11) | Medical Proof of Change in Condition in Support of Application for Reopening | Health Provider | Workers' Compensation Board, with copy to insurance carrier, if known, or employer. | File in a closed case to show change in medical condition supporting reopening of claim. |
| C-64 (1/11) | Proof of Death by Physician Last in Attendance on Deceased | Health Provider | Workers' Compensation Board and insurance carrier/Board-approved self-insurer | Upon death of claimant, or when requested by WCB |
| C-72.1 (1/12) | Record of Percentage Hearing Loss | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or his/her representative. | Upon completion of audiometric test battery. |
| DT-1 (3/12) | Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider | Insurance Carrier or Diagnostic Testing Network | Copy to employee and his/her representative, and health provider. | To Claimant when the statement of Claimant's Rights is mailed - within 14 days of C-2 or with first check per WCL 110 OR when the carrier contracts with a DTN To medical provider when carrier contracts with a DTN, or at time of first medical bill. |
| FCE-4 (1/11) | Practitioner's Report of Functional Capacity Evaluation | Physical or Occupational Therapist | Workers' Compensation Board, insurance carrier, injured employee or his/her representative | See reverse of form for complete filing indications and requirements. |
| HP-1 (4/05) | Health Provider's Request for Decision on Unpaid Medical Bill(s) | Health Provider | Office of Health Provider Administration, 100 Broadway-Menands, Albany, NY 12241 | See detailed instructions and time limits on forms. |
| HP-4 (4/05) | Notice to Chair: Health Provider's and Insurer's Withdrawal of Request for Arbitration | Health Provider or Insurance Carrier/Board-approved self-insurer | Office of Health Provider Administration, 100 Broadway-Menands, Albany, NY 12241 | See reverse of form for filing conditions |
| HP-J1 (7-08) | Provider's Request for Judgment of Award (WCL 54-b) | Authorized Workers' Compensation Health Provider | Workers' Compensation Board Office of Health Provider Administration 100 Broadway - Menands Albany, NY 12241 | For awards/decisions made on or after March 13, 2007. Upon issuance of an administrative award and/or arbitration decision you must wait at least 30 days before requesting consent for judgment. To avoid the complications of filing unnecessary requests, waiting 60 days is recommended. The 60 day time period will allow for carriers' billing/payment cycles. |
| IME-3 (1/11) | Practitioner's Report of Request for Information/Response to Request Regarding Independent Medical Examination | Practioners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board | To report request for information - file within 10 days of receipt of the request. To report response to a request for information - file within 10 days of submission of response. See form for complete instructions. |
| IME-4 (1/11) | Practitioner's Report of Independent Medical Examination | Practioners Authorized by the Board to conduct Independent Medical Examinations | Workers' Compensation Board; insurance carrier or Board-approved self-insured employer; claimant's attending physician or other attending practitioner; the claimant's representative, if any, and the claimant. | Report shall be filed with the Board and provided to all parties on the same day in the same manner. |
| IME-5 (1/11) | Claimant's Notice of Independent Medical Examination | Health Provider or Insurance Carrier | Mail to the claimant, and Workers' Compensation Board. | Claimant must receive notice by mail at least seven business days prior to the scheduled examination. |
| IME-7 (4/05) | Statement of Registration (Sec. 13n -WCL) | Entities deriving income from independent medical examinations | Office of Health Provider Administration, 100 Broadway-Menands, Albany, NY 12241 | A completed registration form and receipt of a registration number assigned by the Board are required for all IME entities conducting business on or after March 20, 2001. File as soon as possible. Statement must include the notarized signature of an officer of the company, and must be accompanied by a $250 registration fee. |
| IS-1 (2-13) | Physician's Application for Designation as an Impartial Specialist | Physician seeking Impartial Specialist designation | Workers' Compensation Board, Medical Director's Office | When applying for designation as an Impartial Specialist | IS-1R (2-13) | Physician’s Application for Renewal of Designation as an Impartial Specialist | Physician seeking renewal of Impartial Specialist designation | Workers' Compensation Board, Medical Director's Office | 60 days prior to the end of your designation term. | IS-4 (2-13) | Physician’s Report of Impartial Specialist Examination or Impartial Specialist Record Review | Physician | Workers' Compensation Board | Within 20 days of the examination or within 25 days of receipt of records. |
| MD-1 (1/11) | Attending Doctor's Request for Medical Authorization Determination | Attending Doctor | Workers' Compensation Board | When a carrier or Board-approved self-insured employer has not responded within 30 days to a request for authorization for special services costing more than $1000. SEE INSTRUCTIONS ON FORM FOR NECESSARY FILING CONDITIONS. |
| MG-1 (2-13) | Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response | Health Care Provider | Workers' Compensation Board and Insurance Carrier | Request confirmation from the Insurance Carrier that the procedure or test is based on a correct application of the Medical Treatment Guidelines. |
| MG-1.1 (2-13) | Continuation to Form MG-1, Attending Doctor's Request for Optional Prior Approval | Health Care Provider | Workers' Compensation Board and Insurance Carrier | Request confirmation from the Insurance Carrier that more than one procedure or test is based on a correct application of the Medical Treatment Guidelines. |
| MG-2 (2-13) | Attending Doctor's Request for Approval of Variance and Carrier's Response | Health Care Provider | Workers' Compensation Board, Insurance Carrier, Injured Employee and his/her representative | To request testing or treatment that is outside or exceeds the Medical Treatment Guidelines. |
| MG-2.1 (2-13) | Continuation to Form MG-2, Attending Doctor's Request for Approval of Variance | Health Care Provider | Workers' Compensation Board, Insurance Carrier, Injured Employee and his/her representative | To request more than one test or treatment that is outside or exceeds the Medical Treatment Guidelines. |
| MR/IME-1 (4/05) | Health Provider's Application for Authorization Under the Workers' Compensation Law | Health Providers | See instructions on form | When seeking authorization to render care under the Workers' Compensation Law, or to conduct Independent Medical Examinations under the Workers' Compensation Law, or both. |
| MR-4 (1/11) | Impartial Specialist's Report of Medical Records Review | Impartial Specialist | Workers' Compensation Board | When the Board has requested an Impartial Specialist Medical Records review on procedures that require pre-authorization under Medical Treatment Guidelines. |
| OT/PT-4 (1/11) Paper Version
[OT/PT-4 On-lineSubmission] |
Occupational/ Physical Therapist's Report | Occupational/ Physical Therapist | Workers' Compensation Board, insurance carrier, referring doctor, injured employee or his/her representative. | 48 hour initial report, within 48 hours of first treatment. 15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
| PS-4 (1/11) | Psychologist's Report | Psychologist | Workers' Compensation Board, insurance carrier, injured employee or his/her representative. | 48 hour initial report, within 48 hours of first treatment. 15 day report, after treatment is first rendered. 90 day progress report, at 90 day intervals while continuing treatment. |
If the form you are looking for is not listed above, or in the list of Common Board Forms, please contact the Board.
