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Workers' Compensation Board

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Medical Treatment Guideline Variance Request

When to submit a Variance Request

A variance request should be submitted when a treating medical provider needs to request treatment that is not consistent with the Medical Treatment Guidelines (MTG). This includes requests to extend treatment beyond the maximum duration or frequency recommended in the MTG, or requests for treatment that is not recommended or not addressed in the MTGs. A variance must be requested and approved before treatment is provided. For additional information on requests for variance approvals, please read Medical Treatment Guidelines Regulations

How to Submit a Variance Request

  1. Complete:
  2. Search for the insurance carrier's designated contact
    • Note: Failure to submit the request to the designated contact identified on the Workers' Compensation Board website may result in your request being denied.
    • Typing the Insurer's ID (W#) or name in the search box directly above the table will help to narrow the list.

    • Search for Contacts
  3. Within two (2) business days of the date the form is prepared:
    • Fax or email the form to the insurer's designated fax/email address. If you are unable to send or receive fax or email, mail the form with a return receipt requested. If the Claim Administrator (Insurer or Third Party Administrator) asks that an alternate contact be used, identify the alternate contact on the form and send the request to both the designated and alternate contact..
    • On the same day also send a copy to the:
      • Workers' Compensation Board using one of the prescribed methods of same day transmission (fax, email or Web Upload).
      • patient and the patient's legal representative if any.

Determining the Insurance Carrier

You can use Does Employer Have Coverage? to find the name of the employer's insurance carrier. If several insurers are listed for that employer, choose the one who provided coverage during the injured worker's date of accident. Occasionally, the system will identify the insurer for the date of accident as "SELFINS". If this occurs, please call (518) 402-0247 to identify the actual insurer.

Contact Us

Please email general_information@wcb.ny.gov or call (877) 632-4996 if you have questions regarding this form.