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Workers’ Compensation Board

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The New C-4 Family of Forms:
Frequently Asked Questions

Common questions about the introduction of the new group of forms for health care providers are answered below.

  1. The revised C-4 requires more detail than the older version. Can we simply attach office notes or a narrative, in lieu of completing the entire C-4? On Sept. 16, the Board released four new and revised forms.
    • Doctor's Initial Report, C-4.0 (revised)
    • Doctor's Progress Report, C-4.2 (new)
    • Doctor's Report of MMI/Permanent Impairment, C-4.3 (new)
    • Attending Doctor's Request for Authorization and Carrier's Response, C-4 AUTH (new)

    These are all available for use now. Providers must use them for dates of service on, or after, April 1, 2009. Originally, medical providers were required to utilize the new C-4 forms by January 1, 2009, however the Board has announced a three month extension to the original transition period after receiving numerous requests from medical providers to delay the mandatory use of the new forms. Please answer all questions on the forms. If you wish to submit a narrative report, you can use the new EC-4 NARR form.

    Every medical report, including the EC-4NARR, filed through the WCB web site is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540). The Doctor's Narrative Report (EC-4NARR) form will only be accepted through web submission of the Board's on-line EC-4Narr or through the XML batch submission process. The Board will accept the Doctor's Narrative Report (EC-4NARR) as an equivalent to the C-4 and C-4.2.

    EC-4Narr Overview
    • Web Submission Requirements
      • The health care provider must be authorized by the NYS Workers' Compensation Board. If you are not an authorized health care provider and would like to become one, complete and submit Health Providers Application for Authorization Under the Workers' Compensation Law MR/IME-1 adobe pdf
      • If the health care provider does not already have a user ID and password to submit claim forms from the Board's web site, they must register and a user ID and password will be assigned to them. This process may take up to a week.
      • Medical narratives must be attached. Please read "Attachment Requirements".
      • Upon successful submission, the health care provider will be provided with a printable PDF version of the form to keep for their records and to be used to send required copies of EC-4Narr and all attachments to the insurance carrier and to the patient's attorney or licensed representative if he/she has one, if not send a copy to the patient. DO NOT MAIL THIS FORM TO THE BOARD.
    • Additional Features
      • Incomplete forms can be saved locally then completed and submitted through the Board's web site at a later time.
      • Template files with standard information (doctor, patient, employer) can be saved and used as a basis for web submission of future reports.
    • XML Batch Submissions
  2. Why is the new C-4 form so much longer than the old one? The Board changed the C-4 to strengthen the entire workers' compensation system for all parties, providers included. More information is now gathered up front for each case. That will reduce the number of disputed cases, so benefits will flow more quickly to injured workers. Provider reimbursement will therefore arrive faster. This increased emphasis on information accelerates the pace of all cases, so benefits across the system should see less delay. It is important to note, however, that the amount of additional information required to fill out the new form is less than might be expected by a simple comparison of the length of the old and new forms.

    One reason why the one-page C-4 is now four pages is simply better presentation. The new form is clearer and easier to read. The typeface is larger, there is more space to answer questions, and more white space is used between fields. That alone adds a whole page.

    There are now three questions regarding symptoms and nature of injury that are answered with checkboxes. For purposes of data collection, the form provides a grand total of 53 checkboxes, which adds another page. Those three questions require a minimal time to answer.

    There are less than a dozen new questions. Some are as simple as patient gender. Providers will only use the C-4 on the initial visit. Subsequent care is reported on the two-page C-4.2. Providers may also want to use the EC-4 NARR, a one-page, electronic form that allows you to attach treatment notes, in place of both the C-4 and C-4.2.

    The C-4 family of forms are more than a medical report or bill for services rendered. They constitute your testimony of a claimant's condition, so that you do not need to come to a Board office and testify.
  3. If we complete all sections of the revised and new forms, will we still be required to attach office notes and narratives? A completed form C-4.0 (for initial visit) or C-4.2 (for subsequent care) should suffice in most cases. However, office notes and narratives reports should be included if there is medical information that cannot be included on the forms, or if the New York Workers' Compensation Medical Fee Schedule ground rules require that narrative reports be included. You can submit narrative reports with the EC-4 NARR.
  4. Is it true that beginning April 1, 2009, the Board will only accept the new and revised forms electronically? No, we will still accept paper forms. If you find it easier or otherwise advantageous to file electronically, we have introduced an electronic-only form, the EC-4 NARR. You can also file most of the revised and new forms online, but it's not mandatory. In fact, the C-4 AUTH form may only be filed on paper.
  5. The space for the carrier case number on the revised C-4.0 is shorter than the space on the previous C-4. Carrier case numbers can be very long. Does the Board plan to revise this form to accommodate more space for the carrier case number? Yes. In response to provider suggestion, the Board has revised the form.
  6. Will the Board accept the HCFA-1500 (CMS-1500) form with attached office note or narratives instead of a completed C-4 form, and if not, can a HCFA-1500 (CMS-1500) be submitted with a completed C-4 form for billing purposes only? With the exception of physicians treating an injured worker in an emergency room or an out of state medical provider, all physicians, chiropractors, and podiatrists must utilize the new C-4 forms when reporting dates of service on, or after, April 1, 2009. The billing section of a paper version of a C-4 form may be left blank and a completed CMS-1500 (HCFA-1500) form may be included, however all other sections of the C-4 form(s) must be completed.
  7. Is there a way that we can link our present software to your web site so that we are not doing double entry on all our patients? Does the Board provide software that we can incorporate into our existing billing software? The Board is actively working with major developers of medical billing and practice management software, as well as software intermediaries, for just this purpose.
  8. After we electronically submit a C-4.2 to the Board, can we transfer the information from that completed C-4.2 form to subsequent C-4.2 submittals? A version of the C-4.2 with that feature is planned for release in the future. However, the EC-4 NARR provides that capability.
  9. Should health care providers use the new and revised health care provider forms immediately? Yes. The C-4.0, C-4.2, C-4.3 and C-4 AUTH were introduced on Sept. 16, 2008.
  10. What is the deadline for implementing the new forms? Medical providers must utilize the new C-4 family of forms for dates of service on, or after, April 1, 2009. The Board has announced this in Subject Numbers 046-273, 046-301 and 046-301R.
  11. What are the repercussions for the medical provider if the previous version of the C-4 or HCFA-1500 forms are submitted to the Board and/or the carrier after March 31, 2009? Medical providers who do not use the new C-4 forms, on or after, April 1, 2009 will be penalized. If the medical provider fails to 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 medical provider 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.
  12. During the development process of the forms, was the medical community allowed the opportunity to provide input? The Board actively sought and received a great deal of input from the medical community during this redesign. We met with a group of providers on Nov. 8, 2007 at the beginning of this process. Between Dec. 11, 2007, and Jan. 24, 2008, the Board posted the revised C-2, C-3, C-4, and C-4.2 forms on its web site for input from the general public, including medical providers. The Board received 340 survey responses. Last March, the Board contracted with a focus group expert to design and facilitate three different focus group sessions across the state just for medical providers, and feedback was collected from the medical providers in attendance. After each step in the process, suggestions were evaluated and changes were incorporated. We have also met with groups representing the health care community, such as the Medical Society of the State of New York and the Chiropractic Assoc. We continue to receive and consider correspondence, as well.
  13. Are hospitals required to submit a C-4 form or can they continue to submit bills with a UB-04 form? Hospitals may continue to submit the UB-04 form for services provided. However, this form is primarily a billing form, so a medical report must be submitted in order for the insurance carrier to properly consider the bill. The report will also provide the necessary documentation required in support of the claimant's case.
  14. Can the various forms be incorporated into any medical billing software, or must we use the actual Board form? If so, can the Board logo be removed? Can the entire form be in black and white rather than having the upper headings and fields in blue? Is there any leeway in the vertical and horizontal spacing? Where can we address questions? A software company can incorporate any of the Board forms into its software package, but the form used must be similar to the prescribed Board form. Minor variations such as spacing are acceptable. The forms can be duplicated in black and white without the use of the blue color. The Board logo must be included on the form. The Board can supply a computer file for anyone requesting a Board logo for their system. A request for a Board logo and/or any significant variations to the forms must be submitted to the Board for approval at
  15. If we submit completed forms electronically, will the carrier or self-insured employer also receive this submission at the same time? Not at this time, but in response to provider inquiries, we are working with software developers and intermediaries to achieve this. In web-based submissions, the carrier or self-insured employer will not receive the completed forms in the same transaction as the Board. A copy must be sent to both the carrier or self-insured employer, and to the claimant (or claimant's attorney if represented). You can print copies of your Board submission.
  16. Our software vendor has re-created the forms for our medical practice and we can simply save information placed on the C-4 and transfer it to the C-4.2 and C-4.3 reports. The carrier name and address on the C-4 form does not appear on the C-4.2 and the C-4.3reports, so when we send the C-4.2 and C-4.3 reports to the carrier, we have to refer back to the patient's file to find carrier information. Can this information be added to the C-4.2 and C-4.3forms? Yes. In response to provider suggestion, the Board has revised the C-4.2 and C-4.3 forms and is in the process of updating the electronic version of these forms.
  17. We would like to save on paper and printing costs by not printing the instruction page (the last page) of the forms. Is this allowed? Will the Board or the carrier reject the report if this page is not sent? While claimants must receive the instruction page, because it includes information they need, you do not need to send the instruction page to the carrier or the Board. Carriers may not reject your filing if it is not attached.
  18. Can we print and submit the forms two sided, and can the completion of the forms be hand-written? Two-sided forms can be submitted, and the forms can be hand-written as long as the information is legible. Electronic submission is the preferred method of filing.
  19. Why do the various forms refer to the New York Treatment and Impairment Guidelines and the list of pre-authorized procedures when these initiatives have not yet been adopted? In response to suggestions from the provider community, these items were included on the forms as placeholders so the forms would not have to be revised once the treatment and impairment guidelines and the list of pre-authorized procedures are adopted. However, given newly raised concerns, we are removing them for the present and will restore them when the Treatment and Impairment Guidelines and the list of pre-authorized procedures are adopted.
  20. The previous C-4 form indicated that a report was required to be submitted 15 days after the initial 48 hour report. The new C-4.2 form does not make reference to the 15 day report. Is this still required? The 15 day report is no longer required.
  21. The previous C-4 form had a space in box 15 for the patient's account number assigned by our office. This is necessary in order for us to track our bills in our billing system. The revised forms do not have a field for patient account number. Does the Board plan to revise this form to accommodate this? The Board has revised the C-4 to include the patient account number.
  22. Why do the new forms include the medical provider's National Provider Identification number when the previous C-4 did not? The requirement that all physicians have an NPI number is a relatively recent development. Although the Board is not using the NPI numbers at this time, a field for the NPI number is included on the C-4 forms to be consistent with nationally recognized electronic billing practices. This is not a mandatory field.
  23. Are ancillary physicians who do not directly treat claimants, such as radiologists and pathologists, required to complete and submit the new C-4 form, even though a majority of the form applies to medical treatment? Sections E through I of the form apply to the treating physician, so radiologists, pathologists and other ancillary medical providers cannot complete these sections of the form. Can these sections be left blank? If so, will the Board and carriers reject the paper and electronic submittals with these sections not completed? Can we continue to submit the previous C-4 form? The Board has released form C-4AMR, Ancillary Medical Report, to be used for ancillary medical services which do not involve treatment. The form can also be submitted to the Workers' Compensation Board electronically by using the EC-4AMR form.
  24. Will the C-4.0 and other new forms be available in Word format, rather than PDF, so medical providers will have the ability to save the information after completion? Word format is not possible. However, providers can use the EC-4 NARR form, which has this feature. The Board is also reviewing other options.
  25. On the C-4.2 form and the C-4.3 the medical provider is asked if the patient would benefit from vocational rehabilitation. Is this meant to imply a referral to ACCES-VR? The question is to solicit information for the carrier to determine the need for vocational rehabilitation for the claimant. ACCES-VR is one but not the sole provider of vocational rehabilitation.
  26. The C-4 AUTH form states the carrier must respond to a request for special services within 4 days if the patient is hospitalized, and 30 days if the patient is not hospitalized. Is the response from the date of the phone call to the carrier or the date the carrier receives the C-4AUTH form? The timeframe's are from the date the carrier receives the written request for authorization from the medical provider.
  27. The C-4AUTH states if the claimant is hospitalized, the response from the carrier must be confirmed in writing by completing this form and mailing it, within 5 business days of the examination of the patient, to the doctor, claimant's legal counsel, and the Workers' Compensation Board. Is the examination of the patient referring to the treating physician's exam or an independent medical exam? The examination refers to an independent medical exam.
  28. Prior to the new C-4 forms, we billed for the physician deposition fees on the C-4. Which C-4 form would we utilize to bill for depositions and a physician's appearance at a hearing? Use the C-4.2 form, because almost all medical testimony is taken during the course of a claimant's treatment plan.
  29. If a C-4.3 form has been submitted, indicating a permanent impairment or maximum medical improvement was reached, and then over a period of time the patient returns to the treating physician for symptomatic treatment, would a C-4.3 or C-4.2 be filed? Use the C-4.2 for all subsequent treatment.
  30. Can C-4.0 forms be sent via e mail to the Board in PDF format rather than through the Board's electronic filing method? Sending completed C-4.0 forms to the Board via e mail is not possible at this time.
  31. Are there grants available to physicians to incorporate these forms with their existing EMR/practice management systems? The Board is working with software firms and intermediaries to create a smooth transition for providers. Workers' Compensation Board grants are not available.
  32. Will the Board provide training on completing the revised C-4 form and other forms? While training is not planned on the proper completion of the C-4 forms, the Board is pursing an extensive outreach program to alert registered providers of all the changes to the C-4 family of forms. Providers may contact the Board with specific questions on completion of the forms. Use or call (800) 781-2362
  33. When using the EC 4 NARR or the EC-4AMR, will all carriers and self-insured employers receive the report/bill electronically? If providers use the Adobe version of the EC-4NARR or the EC-4AMR they have to separately send copies to the carriers. Carriers will have the opportunity to receive the EC-4NARR or the EC-4AMR as part of the XML batch process by working with a Board Authorized XML Submission Partner.
  34. If we are treating an injured worker with injuries to multiple areas of the body how should we report it on the C-4? The C-4 is designed to allow for reporting of multiple injuries for a particular incident. For example, question F.3 on the C-4 asks if multiple areas were burned. Multiple body parts would be listed. If a provider is treating a patient for multiple incidents, each incident would be reported on a separate form.
  35. Will the Board provide providers with blank copies of the new forms? The Board's policy is to provide one original of each form that is requested. All forms may be copied by the user. All forms can also be obtained from the Board's web site.
  36. Why were the C-4 and the C-4.2 forms recently revised in October after being released in September? Based on feedback from medical providers the Board added questions regarding carrier information and removed questions concerning the Medical Guidelines from the C-4 and C-4.2 form.
  37. Section G. of the C-4 requests the medical provider provide the percentage of temporary impairment. The report cannot be submitted unless a numeric value is placed in the percentage of impairment field. How do we determine a percentage of impairment? As a general guideline, medical providers have used mild, moderate, and marked to indicate degree of impairment. The Board's medical guidelines posted on the web site may also be helpful to providers in making this determination. Medical providers may use the following percentages as an initial guide and then use their professional judgment to make a final determination:

    Mild = 25%
    Mild to Moderate = 33.33%
    Moderate = 50%
    Moderate to Marked = 66.67%
    Marked = 75%
    Total = 100%

    If the claimant has been already classified with a permanent impairment, the medical provider can indicate the permanent partial disability percentage at the time of the final classification. If this is not known, medical providers should use their professional judgment to indicate percentage of impairment.
  38. Are chiropractors permitted to determine degree of impairment? While the New York State Education Law does not specifically state that this determination is within a chiropractor's scope of practice, they are not restricted from doing it. Chiropractors can give an opinion on degree of impairment within their scope of practice, which is disability related to the vertebral column.
  39. In the last section of the C-4 and C-4.2 forms, what it meant by the statement, "I actively supervised the health care provider named below who provided these services"? Under the active and personal supervision of a licensed and Board authorized physician, medical care may be rendered, by a person employed by the physician, within the scope of such person's specialized training and qualifications. (ie; a nurse practitioner, physician's assistant, laboratory or diagnostic technician, physical or occupational therapist). In the event this occurs, the person rendering care should be named on the C-4 form(s) and the Board authorized physician must sign the form.
  40. We began treating an injured worker prior to the Board's release of the new C-4 forms, and we continue to provide treatment. Should we continue to submit the previous C-4 form or begin using the new C-4.2 form for continuous treatment? Going forward, health care providers should begin using the new C-4 series of forms.
  41. The first line on the C-4.2 progress report asks for the date(s) of examination. There is only space for one date. How is this to be completed if there are multiple examination dates within the 45 day reporting period? The Board updated the C-4.2 form to allow for multiple examination dates.
  42. Item #2 of the Examination and Treatment section of the C-4.2 report requires the provider to list any changes to the area of injury, the patient's complaints, or the provider's findings. Often times the narrative explains these changes in much more detail than the form allows space for. Is it acceptable to write, "see attached narrative" on the form? Yes.
  43. Certain software programs can store the physician's electronic signature. Will an electronic signature on the paper versions of the C-4 forms be acceptable? Physicians may affix the electronic signature to paper versions of the C-4 forms after review and approval of the medical report. The electronic signature should be unique to the physician with a unique user I.D. and a password only known by them.
  44. Most anesthesiologists only provide anesthesia for surgeries performed by another physician, and do not examine or treat patients. Most of the sections on the C-4 reports regarding examinations, plan of care, doctor's opinion, work status, and treatment do not apply. Can anesthesiologists complete the general information on the C-4 forms and attach a report? Anesthesiologists providing a medical service not involving treatment may now use form C-4AMR or the EC-4AMR(electronic version), Ancillary Medical Report. A report of the services provided must be included when submitting the form.
  45. Most chiropractors use SOAP notes (Subjective, Objective, Assessment, and Plan), and not narratives. These notes are recorded manually for each office visit and are a nationally recognized practice. How will chiropractors be able to incorporate their SOAP notes when filing reports electronically using the EC-4NARR? In order to use the EC-4NARR, the provider would need to create and attach an electronic version of the SOAP notes through scanning or some other process.
  46. The Board announced it will accept the EC-4NARR as an equivalent to form C-4.2 Progress Report. This progress report can accommodate multiple visits within the required 45 day reporting period, for which there is a separate narrative for each office visit. Will the filing of the EC-4NARR allow for multiple narratives to be submitted that correspond with each office visit? Yes, the EC-4NARR will allow for multiple file attachments.
  47. There are certain questions on the form(s) that cannot be answered due to the type of medical provider, or due to the type of service being performed. Can the questions be left blank, and if not, what wording should be provided so the Board and the carriers will not reject submission of the forms? If a question can not be answered it can be left blank. For ancillary physicians who do not directly treat claimants, such as radiologists, pathologists and anesthesiologists, the C-4AMR should be utilized.
  48. Is the utilization of C-4 AUTH form required for requesting authorization for special medical services, or can we continue using our current office practice to request authorization? The C-4 AUTH form was developed to expedite medical treatment of injured workers by developing a faster process for the Board to issue an Order of the Chair to the medical provider in the event the insurance carrier or self-insured employer fails to respond timely to the request for authorization. The 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 ensure that all statutory timeframes are met.

    Failure of the medical provider to utilize the C-4 AUTH form does not relieve the carrier or self-insured employer from timely responding to a request for authorization, nor does it prevent the Board from issuing an Order of the Chair pursuant to 12 NYCRR 325-1.4(7). The Board strongly encourages medical providers to incorporate the use of the C-4 AUTH form into their office practices so that appropriate treatment is not delayed. If the medical provider seeks an Order of the Chair and does not utilize the C-4 AUTH form, the provider must submit a letter to the Board requesting an Order of the Chair and include a copy of the original request for authorization that was submitted to the carrier or self-insured employer. A copy of the letter requesting an Order of the Chair must also be sent to the carrier or self-insured employer.
  49. Multiple physicians within our practice are authorized to treat injured workers, and would like to file the C-4 forms electronically. Do we need to register each provider individually to file electronically? If your providers expect to submit over the WCB web site, each individual provider must register with the Board for a unique ID and password. If the practice chooses to submit the EC-4NARR or the EC-4AMR as a batch XML submission then the practice would register with the Board and each individual provider must sign a legal agreement with the Board to permit the practice to send forms electronically under their authorization number.
  50. If we submit on an EC-4NARR or an EC-4AMR and the carrier is not set up to receive the report electronically, will we have the ability to print out the completed EC-4NARR or the EC-4AMR, or will we have to complete a paper version of the C-4, the C-4.2, or the C-4AMR to mail to the carrier? You will have the ability to print the EC-4NARR and the EC-4AMR.
  51. Do private practice physicians treating workers' compensation patients in an emergency room have to complete the C-4 for every workers' compensation patient? No. Physicians can submit their usual billing form along with an emergency room report to the Board and the carrier.
  52. We are a large practice and submit our claims for reimbursement to various carriers electronically using ANSI 837 electronic claims submission. Can we continue this practice, and if so, must we continue to submit C-4 forms to the Board and the carrier? You may continue filing ANSI 837 electronic claims to the carrier, however a completed C-4 form must also be submitted to the Board and the carrier.
  53. The C-4 form(s) requires the insurance carrier "W" number. If we do not know the number, may we leave it blank? If not, how do we obtain this number? The "W" can be left blank or you can call WCB customer service and ask for it. [WCB Customer Service Toll–Free Number (877) 632-4996].
  54. Can the C-4 forms be faxed to the Board? Yes. Forms and attachments can be faxed to 1-877-533-0337. A fax cover is not required, however the Board needs the injured workers name, social security number (if known), and date of accident to be able to place the C-4 report in the correct case file. The WCB case number should also be included, if known.
  55. Does the April 1, 2009 date for mandatory utilization of the C-4 forms apply to the dates of service, or the date the medical provider submits the completed forms? It applies to the dates of service.
  56. Are physicians who are treating an injured worker who is hospitalized required to utilize the new C-4 forms? Yes
  57. Do self -employed physical and occupational therapists utilize the new C-4 forms? No. Self employed physical and occupational therapists must utilize the OT/PT-4 form.
  58. Do psychologists and ophthalmologists, utilize the new C-4 forms? No. psychologists utilize the PS-4 form and ophthalmologists utilize the C-5 form.
  59. When re-creating the C-4 form(s) into our practice management software, is it acceptable to list the restrictions in the return to work section rather than showing the various check boxes? Yes
  60. Do the various paper versions of the C-4 forms require an actual signature of the medical provider, and if so, does it have to be an original signature? The paper version of the C-4 form(s) must be signed by the authorized medical provider. The signature can be the original or a stamp or an electronic signature as long as the medical provider has the intent to sign the completed form. The provider must review and approve each completed form. Also, someone else cannot sign the medical provider's name.
  61. Can self-employed physical and occupational therapists or free standing physical and occupational therapy practices request authorization for physical and occupational therapy, and if so, can they utilize the C-4AUTH form? A self-employed physical or occupational therapist (or free standing physical or occupational therapy practice) upon receipt of a prescription or referral from an authorized physician may render care and can request authorization and re-authorization for physical and occupational therapy, in accordance with 12 NYCRR §325-1.4, and Part 8, Physical Medicine, Ground Rule 8 of the Official New York Workers' Compensation Medical Fee Schedule. The C-4 AUTH form or the OT/PT-4 form may be utilized to request authorization, however utilization of the C-4AUTH form has the benefit of the issuance of an Order of the Chair from the Board in the event the insurance carrier or self-insured employer fails to respond timely to the request for authorization. The injured worker's treating physician may also request authorization for physical or occupational therapy on a C-4AUTH form.
  62. Can a medical provider such as a cardiologist or a primary care physician who is only giving clearance for surgery, and is not providing treatment of the work related injury or illness, utilize the C-4 AMR Ancillary Medical Report form? Yes. The C-4 AMR Ancillary Medical Report form (or the EC-4 AMR on-line submission form) may be utilized, however a report must be submitted with it.

Updated 7/17/09