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 Workers' Compensation Forms for Health Care Providers

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. WCB periodically releases new versions of certain forms to obtain additional information, streamline processing, and/or make it easier to complete the form.

Section E includes questions regarding permanent partial impairment. If there is no permanent partial impairment (Question 1) do not file this form, instead use Form C-4.2 (Dr's. Progress Report), unless requested by the Workers' Compensation Board to render a decision on MMI and/or permanent partial impairment. For more information on evaluating

Use this form to report the first time you treated the patient. (To report continued treatment, use Form C-4.2. To report permanent impairment, use Form C-4.3.)

1.This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case as follows: To confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation or

(To report the first time you treated the patient, use Form C-4. For continuing treatment, use Form C-4.2.) Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board and to the insurance carrier.

2012年5月5日 · Form C-4.3, created by the Workers’ Compensation Board in January 2012, represents somewhat drastic changes in the way that physicians document permanent impairments in New York State Workers’ Compensation claims. The new form has been modified to accommodate the 2012 permanency guidelines.

If your injury was the result of the use or operation of a licensed motor vehicle: If you filed a Department of Motor Vehicles Form MV-104 (Report of Motor Vehicle Accident), please submit a copy along with the C-3. This will expedite the process for you to receive potential benefits.

Use this form to report the first time you treated the patient. (To report continued treatment, use Form C-4.2. To report permanent impairment, use Form C-4.3.)