C-4.3. Use this form: 1. When rendering an opinion on MMI and/or permanent partial impairment; or 2. In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent partial impairment.

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. Health providers are permitted to obtain the claimant's agreement to pay usual and customary fees in the event claim is not prosecuted or is disallowed.

2022年7月1日 · The Doctor's Report of MMI/Permanent Impairment (Form C-4.3) is used (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 on MMI and/or permanent impairment.

2022年3月13日 · 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 on MMI and/or permanent impairment.

Use this form when a patient has reached Maximum Medical Improvement and to render an opinion on permanent impairment, if any. (To report the first time you treated the patient, use Form C-4. For continuing treatment, use Form C-4.2.)

When a claimant’s treating physician believes that the claimant has reached Maximum Medical Improvement and/or has a permanent impairment, he or she will complete Form C-4.3 to render an opinion regarding the level of the claimant’s permanent impairment.

The online version of Form C-4.3 is now available for use. Both the online and paper versions have been updated. Please be advised of the following changes: The billing section has been simplified with space to include information from just one exam.

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 on MMI and/or permanent impairment.