Health Care Providers Workers' Compensation Forms (2024)

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

• Physician
• Nurse Practitioner
• Physician Assistant
• Podiatrist
• Chiropractor
• Licensed Clinical Social Worker

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

• Physician
• Nurse Practitioner
• Physician Assistant
• Podiatrist
• Chiropractor
• Licensed Clinical Social Worker

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 OnlineSubmission]

Doctor's Report of MMI/Permanent Impairment

• Physician
• Nurse Practitioner
• Podiatrist
• Chiropractor
• Psychologist
• Licensed Clinical Social Worker
• Physician Assistant*

  *PA services may only be provided under the direct supervision of a physician.

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

• Physician
• Nurse Practitioner
• Podiatrist
• Chiropractor
• Psychologist
• Licensed Clinical Social Worker
• Physical Therapist
• Occupational Therapist
• Acupuncturist

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

• Physician
• Nurse Practitioner
• Physician Assistant
• Podiatrist
• Chiropractor
• Psychologist
• Licensed Clinical Social Worker

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 WCBC-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 insurer contracts with a DTN

To medical provider when insurer contracts with a DTN, or at time of first medical bill.

• Translated forms: Español | Русский | Polski | 中文 | Italiano | Kreyòl ayisyen | 한국어 | বাঙালি | יידיש | عربى | Français | اردو

FCE-4 (1/11)Practitioner's Report of Functional Capacity EvaluationPhysical or Occupational Therapist Workers' Compensation Board, insurance carrier, injured employee or their representativeSee 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 SuppliersMust be submitted online using OnBoardForm 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 ArbitrationHealth Provider or Insurance Carrier/Board-approved self-insurerMedical Director's Office, Riverview Center, 150 Broadway – Suite 195, Menands, NY 12204See reverse of form for filing conditionsHP-J1 (1/24)Provider's Request for Judgment of Award (WCL 54-b)Authorized Workers' Compensation Health ProviderWorkers' Compensation Board Office of Disputed Medical Bills Unit, 328 State Street, Schenectady, NY 12305For 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 insurers' billing/payment cycles.IME-3 (7/14)Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical ExaminationIndependent 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 ExaminationIndependent Examiners Authorized by the Board to conduct Independent Medical ExaminationsWorkers' 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 UseIndependent Examiners Authorized by the Board to conduct Independent Medical ExaminationsWorkers' 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 DisabilityIndependent Examiners Authorized by the Board to conduct Independent Medical ExaminationsWorkers' 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 examinationsMedical Director's Office, Riverview Center, 150 Broadway – Suite 195, Menands, NY 12204A 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 SpecialistPhysician seeking Impartial Specialist designationWorkers' Compensation Board, Medical Director's OfficeWhen applying for designation as an Impartial Specialist IS-1R (2/13)Physician’s Application for Renewal of Designation as an Impartial SpecialistPhysician seeking renewal of Impartial Specialist designationWorkers' Compensation Board, Medical Director's Office60 days prior to the end of your designation term. IS-4 (2/13)Physician’s Report of Impartial Specialist Examination or Impartial Specialist Record ReviewPhysicianWorkers' Compensation BoardWithin 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

• Physician
• Nurse Practitioner
• Podiatrist
• Chiropractor

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

• Occupational Therapist
• Physical Therapist

Workers' Compensation Board, insurance carrier, referring doctor, injured employee or their representative48 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 ReportPsychologistWorkers' Compensation Board, insurance carrier, injured employee or their representative48 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 AffirmationPhysician AssistantWorkers' Compensation BoardAttached to Initial Request for Authorization and whenever a new supervising physician is reported to the Board.