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.

2022年7月1日 · Please Note: 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. To submit the web version of the C-4.3, the health care provider must be authorized by the NYS Workers' Compensation Board. Apply for Authorization

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.

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.)

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.

2022年3月13日 · The C-4.3 has been modified to accommodate the 2018 Workers' Compensation Guidelines for Determining Impairment, while continuing to reflect the 2012 Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity.

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.