Subject Numbers Regarding Health Provider Authorizations

Authorization No. 135796-1W

May 6, 2013

Please be advised that Dr. Clifford Jacobson's authorization to treat injured workers in the New York State workers' compensation system has been suspended indefinitely effective April 2, 2013. Dr. Jacobson's last known business address is 1655 Elmwood Avenue, Rochester, New York, 14620.

Dr. Jacobson is prohibited from rendering treatment and care to injured workers while his authorization is suspended. Reports submitted by Dr. Jacobson for services rendered prior to April 2, 2013, are valid, but are invalid for any services rendered on or after that date. Requests to cross-examine Dr. Jacobson for services rendered prior to April 2, 2013, should not be denied due to the suspension of his authorization.

Any questions regarding the authorized lists should be referred to the Medical Director’s Office at 1 (800) 781-2362.