Workers Compensation C 4 Form is a form that you must fill out to get workers compensation.
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Workers Compensation C 4 Form PDF Details
Are you required to submit a workers compensation C 4 form? What is it, and what information does it include? In this blog post, we'll provide an overview of the workers compensation C 4 form and explain why it's important. We'll also help you understand what happens if you fail to submit this document.
Below is the information regarding the form you were looking for to complete. It can show you the time it should take to complete workers compensation c 4 form, exactly what fields you need to fill in and a few other specific facts.
Question | Answer |
---|---|
Form Name | Workers Compensation C 4 Form |
Form Length | 4 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 1 min |
Other names | ny workers comp c 4 2 form, nys workers compensation c4 forms, nys workers comp c4 form, nys workers comp c4 authorization form |
12
Form Preview Example
IMPORTANT:
PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING HOW TO FIND
A.
ATTENDING DOCTOR'S REQUEST FOR | ||||||||||
AUTHORIZATION AND INSURER'S RESPONSE | ||||||||||
Answer all questions fully on this report | AUTH | |||||||||
WCB Case #: | Claim Administrator Claim (Carrier Case) #: | Date of Injury/Illness: | ||||||||
Patient's Name: | First | MI | Last | Social Security No.: | ||||||
Address: | ||||||||||
Employer Name: | Number and Street | City | State | Zip Code | ||||||
Address:
Number and Street | City | State | Zip Code | ||||
Insurer Name: | |||||||
Address: | |||||||
B. | Number and Street | City | State | Zip Code | |||
Attending Doctor's Name: | |||||||
Address: |
Number and Street | City | ||||||||||||||
Individual Provider's WCB Authorization No.: | - | ||||||||||||||
Telephone No.: | Fax No.: |
State | Zip Code |
NPI No.:
C.
AUTHORIZATION REQUEST
The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring
Authorization Requested: | Insurer Response: if any service | ||||||||||||||
Diagnostic Tests: | is denied, explain on reverse. | ||||||||||||||
Granted | Granted w/o Prejudice | Denied | |||||||||||||
Radiology Services | |||||||||||||||
Other | Granted | Granted w/o Prejudice | Denied | ||||||||||||
Therapy (including Post Operative): | |||||||||||||||
Physical Therapy: | times per week for | weeks | Granted | Granted w/o Prejudice | Denied | ||||||||||
Granted | Granted w/o Prejudice | Denied | |||||||||||||
Occupational Therapy: | times per week for | weeks | |||||||||||||
Other | Granted | Granted w/o Prejudice | Denied | ||||||||||||
Surgery: | |||||||||||||||
Type of Surgery (Describe, include use of hardware/surgical implants) | Granted | Granted w/o Prejudice | Denied | ||||||||||||
Granted | Granted w/o Prejudice | Denied |
Treatment:
Other
Granted
Granted w/o Prejudice
Denied
Medical Treatment Guidelines Procedures Requiring
1. | Lumbar Fusions | 1. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
B | - | E | 4 | a | ............................................................................. | ||||||||||||||||||||||||||||||||||||||||||||||||||
2. Artificial Disk Replacement | 2. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
- | E | ........................................................... | |||||||||||||||||||||||||||||||||||||||||||||||||||||
3. | Vertebroplasty | 3. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
B | - | E | 7 | a | i | ................................................................................ | |||||||||||||||||||||||||||||||||||||||||||||||||
4. Kyphoplasty | 4. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
B | - | E | 7 | a | i | .................................................................................... | |||||||||||||||||||||||||||||||||||||||||||||||||
5. | Electrical Bone Growth Stimulators | 5. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
- | E | a | ............................................... | ||||||||||||||||||||||||||||||||||||||||||||||||||||
6. | Osteochondral Autograft | 6. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
K | - | D | 1 | f | ................................................................ | ||||||||||||||||||||||||||||||||||||||||||||||||||
7. Autologous Chondrocyte Implantation | 7. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
K | - | D | 1 | f | ............................................. | ||||||||||||||||||||||||||||||||||||||||||||||||||
8. Meniscal Allograft Transplantation | ................................................. | 8. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
K | - | D | |||||||||||||||||||||||||||||||||||||||||||||||||||||
9. Knee Arthroplasty (total or partial knee joint replacement) | 9. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
K | - | F | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
10. Spinal Cord Stimulators | 10. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||
P | - | G | 1 | ................................................................. | |||||||||||||||||||||||||||||||||||||||||||||||||||
11. Intrathecal Drug Delivery (pain pumps) | ......................................... | 11. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
P | - | G | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||
12. Second or Subsequent Procedure | ................................................ | 12. | |||||||||||||||||||||||||||||||||||||||||||||||||||||
- |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
Granted | Granted w/o Prejudice | Denied |
D.
STATEMENT OF MEDICAL NECESSITY
Pursuant to 12 NYCRR
Date of service of supporting medical in WCB Case File:(Attach if not already submitted.)
Pursuant to 12 NYCRR 325.1(a)(3), the treating provider shall submit this form to the Workers' Compensation Board and insurer.
Providers must complete Part A below indicating that the request was sent to the
A.Insurer's designated fax # or email address as provided on the Board's website:
B. If the request was also submitted to another fax # or email address provided by the insurer, provide here:
C.I am not equipped to send or receive forms by fax or email. This form was mailed (return receipt requested) on:
If you called the insurer and spoke with an individual, provide the date of the call: and name of person contacted:
Designated contact information not available.
I certify I am making the above request for certification. This request was made to the insurance
Provider's Signature: | Date: |
Response Time and Notification Required:
The
Denial of the Request for Authorization of a Special Service: A denial of authorization of a special service must be based upon and accompanied by a conflicting second opinion rendered by a physician authorized to conduct IMEs, or record review, or qualified medical professional, or a physician authorized to treat workers' compensation claimants. (If authorization is denied in a controverted case, the conflicting second opinion must address medical necessity only.) Failure to file timely the conflicting second opinion will render the denial defective. If denial of an authorization is based upon claimant's failure to attend an IME examination scheduled within the 30 day authorization period, contemporaneous supporting evidence of claimant's failure must be attached.
Failure to Timely Respond to Form
REASON FOR DENIAL(S), IF ANY. (ATTACH OR REFERENCE CONFLICTING SECOND MEDICAL OPINION AS EXPLAINED ABOVE.)
Date of service of supporting medical in WCB case file:
I certify that the
and
I certify that copies of this form were emailed, faxed, or mailed to the treating provider, the claimant (patient), the claimant's legal representative, if any, the Workers' Compensation Board and all parties of interest on the date below:
By: (print name) | Title: | |||||
Signature: | Date: |
www.wcb.ny.gov |
REQUEST FOR WRITTEN AUTHORIZATION
IMPORTANT TO ATTENDING DOCTOR
AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY
1.This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case to request written authorization for special service(s) costing over $1,000 in a
2.This form must be signed by the attending doctor and must contain her/his authorization number and code letters.
3.Please ask your patient for his/her WCB case # and the claim administrator claim (carrier case) number and show these numbers on this form. In addition, ask your patient if he/she has retained a representative. If represented, ask for the name and address of the representative.
This request must be sent to the Workers' Compensation Board, and the the workers' compensation insurance carrier,
4.The attending doctor must submit this form with the Board and on the same day serve a copy on the
5.If authorization or denial is not forthcoming within 30 calendar days, (or 35 days if
6.SPECIAL SERVICES - Services for which authorization must be requested are as follows:
Physicians - To engage the services of a specialist, consultant, or a surgeon, or to provide for
Podiatrists - In treating the foot, to provide physiotherapeutic procedures,
Occupational/Physical Therapists - In treating a condition as provided in Article 136 or 156 of the Education Law, in the Workers' Compensation Law, and the Rules of the Chair relative to Occupational/Physical Therapy Practice to provide occupational/physical therapy procedures costing more than $1,000.
Psychologists - Prior authorization for procedures enumerated in section
Medical Treatment Guidelines - Lumbar Fusions, Artificial Disk Replacement, Vertebroplasty, Kyphoplasty, Electrical Bone Growth Stimulators, Spinal Cord Stimulators, Osteochondral Autograft, Autologus Chondrocyte Implantation, Meniscal Allograft Transplantation, Knee Arthroplasty (total or partial knee joint replacement), Intrathecal Drug Delivery (pain pumps).
7.If the insurer has checked "GRANTED WITHOUT PREJUDICE" in Section C, the liability for this claim has not yet been determined. This authorization is made pending final determination by the Board. Pursuant to 12 NYCRR §
8.It is the attending doctor's burden to set forth the medical necessity of the special services required. Be sure to provide this information in the Statement of Medical Necessity section of this form.
9.HIPAA NOTICE - In order to adjudicate a workers' compensation claim,
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR
This form must be served on the
www.wcb.ny.gov by fax, email or mailed, return receipt requested. Failure to submit the form to the designated contact identified on the Board's website may result in your request being denied. A copy of the form must also be filed with the Board.
NYS Workers' Compensation Board
PO Box 5205
Binghamton, NY
Email Filing: wcbclaimsfiling@wcb.ny.gov l | Customer Service: (877) |
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION |
How to Edit Workers Compensation C 4 Form Online for Free
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Step 1: Seek out the button "Get Form Here" and select it.
Step 2: So, you are on the file editing page. You may add information, edit current information, highlight specific words or phrases, place crosses or checks, add images, sign the file, erase unrequired fields, etc.
Type in the information demanded by the program to complete the form.
Enter the essential particulars in ATTENDING DOCTORS REQUEST FOR, C AUTH, Claim Administrator Claim Carrier, Date of InjuryIllness, First MI Last, Social Security No, Number and Street City State Zip, Number and Street City State Zip, Number and Street City State Zip, WCB Case, Patients Name, Address, Employer Name, Address, and Insurer Name section.
You will be required certain significant particulars if you need to prepare the Physical Therapy Occupational, Surgery, times per week for times per week, weeks weeks, Granted Granted Granted, Granted wo Prejudice Granted wo, Denied Denied Denied, Type of Surgery Describe include, Treatment Other, Granted Granted, Granted wo Prejudice Granted wo, Denied Denied, Granted, Granted wo Prejudice, and Denied segment.
You should define the rights and responsibilities of both parties in section Knee Arthroplasty total or, Granted, Granted wo Prejudice, Denied, Spinal Cord Stimulators, Granted, Granted wo Prejudice, Denied, Intrathecal Drug Delivery pain, Second or Subsequent Procedure, Granted, Granted, Granted wo Prejudice, Granted wo Prejudice, and Denied.
Finish by checking all these areas and filling them in accordingly: STATEMENT OF MEDICAL NECESSITY, Date of service of supporting, Providers must complete Part A, A Insurers designated fax or, B If the request was also, C I am not equipped to send or, If you called the insurer and, Insurerselfinsurers designated, Designated contact information not, I certify I am making the above, A copy of this form was sent to, Providers Signature, and Date.
Step 3: When you are done, select the "Done" button to transfer your PDF file.
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