Completing Forms
If you require assistance with completing these forms, please contact us.
Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it. Please enter your information, select print and choose Microsoft Print to PDF and submit the saved PDF. Please note, that if you do not Print to PDF, the entered data may not be transmitted resulting in a blank form being submitted. If you have trouble opening a form: (1) download/save the form onto your computer, (2) open Adobe Reader, (3) open the saved file. If you still have trouble with the form, please email the Board's Forms Department.
Multi-page Forms
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.
C-4 Medical Billing Forms
All versions of the C-4 medical billing forms (except the C-4.3) were replaced by the required submission of the CMS-1500 form on July 1, 2022. Learn more about the CMS-1500 Initiative
| Form Number/ Version Date |
Form Title | Who Files | Where to File | When to File |
|---|---|---|---|---|
|
C-4 (8/20) Paper Version [C-4 Online Submission] As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R - Rochester Medical Reporting Information on the CMS-1500 Initiative |
Doctor's Initial Report |
|
Workers' Compensation Board, insurance carrier, injured employee or their 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-4.1 (9/08)
As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R - Rochester Medical Reporting Information on the CMS-1500 Initiative |
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-4.2 (10/15) Paper Version [C-4.2 Online Submission] As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R - Rochester Medical Reporting Information on the CMS-1500 Initiative |
Doctor's Progress Report |
|
Workers' Compensation Board, insurance carrier, injured employee or their 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. |
| C-4.3 (5/22) Paper Version [C-4.3 Online Submission] |
Doctor's Report of MMI/Permanent Impairment |
|
Workers’ Compensation Board, insurance carrier, injured employee or their 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 of MMI and/or permanent impairment. |
|
C-4 AMR (10/15) Paper Version As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R - Rochester Medical Reporting Information on the CMS-1500 Initiative |
Ancillary Medical Report | Provider Other than the Attending Provider | Workers' Compensation Board, insurance carrier, injured employee or their representative | As soon as possible after ancillary treatment or services (such as radiology, pathology or diagnostic services) are rendered. |
| C-4 AUTH (7/18)
As of 5/2/22, this form is no longer being accepted by the Board. All requests are to be submitted using OnBoard. |
Attending Doctor's Request for Authorization and Carrier's Response |
|
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. |
| EC-4NARR (10/15) Online Submission As of 7/1/22, CMS-1500 should be used. See Subject No. 046-1523R - Rochester Medical Reporting Information on the CMS-1500 Initiative |
Doctor's Narrative Report |
|
Workers' Compensation Board, insurance carrier, injured employee or their 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-5 (10/15)
As of 7/1/22, CMS-1500 should be used. Information on the CMS-1500 Initiative |
Attending Ophthalmologist's Report | Health Provider | Workers' Compensation Board, insurance carrier, injured employee or their 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-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 their representative | Upon completion of audiometric test battery. |
| C-100.2 (1/24) | Affidavit for License to Operate an X-Ray Bureau or Laboratory | Bureaus and Laboratories engaged in X-ray diagnosis or treatment. | NYS Workers' Compensation Board Medical Director's Office 150 Broadway, Suite 195 Menands, NY 12204 provider@wcb.ny.gov Fax: 518-408-5599 | Upon registration (or renewal) with the NYS Department of Health (see 10 NYCRR 16.50) |
| DT-1 (3/12) | Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider | Insurance or Diagnostic Testing Network (DTN) can use DT-1 form or a substantially equivalent form to identify one or more DTNs | Copy to employee and employee's representative, and health provider. |
To Claimant when the statement of Claimant's Rights is mailed - within 14 days of receipt of initiating FROI, 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 their representative | See reverse of form for complete filing indications and requirements. |
|
HP-1.0 (3/22)
As of 3/7/22, this is no longer a paper form and all requests are to be submitted via OnBoard. |
Request for Decision on Unpaid Medical Bill(s) | Health Provider and Medical Suppliers | Must be submitted online using OnBoard | Form HP-1.0 may not be submitted if less than 45 days have elapsed from the submission date of the bill or if you have received a timely Notice of Objection to a Payment of a Bill for Treatment Provided (Form C-8.1B) from the claim administrator and the legal objection(s) related to the bill have not yet been resolved. |
| 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 | Medical Director's Office, Riverview Center, 150 Broadway – Suite 195, Menands, NY 12204 | See reverse of form for filing conditions |
| HP-J1 (1/24) | Provider's Request for Judgment of Award (WCL 54-b) | Authorized Workers' Compensation Health Provider | Workers' Compensation Board Office of Disputed Medical Bills Unit, 328 State Street, Schenectady, NY 12305 | 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 (7/14) | Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination | Independent Examiners 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 (5/18)
Implementation of Forms Associated with SLU Evaluations |
Independent Examiner's Report of Independent Medical Examination | Independent Examiners 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-4.3A (5/18)
Implementation of Forms Associated with SLU Evaluations |
Attachment for Report of Independent Medical Examination Scheduled Loss of Use | Independent Examiners 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. | File this form as an attachment to Independent Examiner's Report of Independent Medical Examination, IME-4, for Scheduled Loss of Use. |
| IME-4.3B (5/18)
Implementation of Forms Associated with SLU Evaluations |
Attachment for Report of Independent Medical Examination Non-Scheduled Permanent Partial Disability | Independent Examiners 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. | File this form as an attachment to Independent Examiner's Report of Independent Medical Examination, IME-4, for Non-Scheduled Permanent Partial Disability. |
| IME-7 (1/24) | Statement of Registration (Sec. 13n -WCL) | Entities deriving income from independent medical examinations | Medical Director's Office, Riverview Center, 150 Broadway – Suite 195, Menands, NY 12204 | 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. |
| MG-1 (4/18)
As of 5/2/22, this form is no longer being accepted by the Board. All requests are to be submitted using OnBoard. |
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-2 (4/18)
As of 5/2/22, this form is no longer being accepted by the Board. All requests are to be submitted using OnBoard. |
Attending Doctor's Request for Approval of Variance and Carrier's Response |
|
Workers' Compensation Board, Insurance Carrier, Injured Employee and their representative | To request testing or treatment that is outside or exceeds the Medical Treatment Guidelines. | 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 (7/20) Paper Version [OT/PT-4 Online Submission] As of 7/1/22, CMS-1500 should be used. Information on the CMS-1500 Initiative |
Occupational/ Physical Therapist's Report |
|
Workers' Compensation Board, insurance carrier, referring doctor, injured employee or their 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 (10/15)
As of 7/1/22, CMS-1500 should be used. Information on the CMS-1500 Initiative |
Psychologist's Report | Psychologist | Workers' Compensation Board, insurance carrier, injured employee or their 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. |
| SP-Affirmation (12/19) | Supervising Physician Affirmation | Physician Assistant | Workers' Compensation Board | Attached to Initial Request for Authorization and whenever a new supervising physician is reported to the Board. |
If the form you are looking for is not listed above, or in the list of Common Board Forms, please contact the Board.