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

FORM C-4 PLEASE TYPE OR PRINT EMPLOYEE’S CLAIM – PROVIDE ALL INFORMATION REQUESTED First Name M.I. Last Name Birthdate Sex M F Claim Number (Insurer’s Use Only) Home Address Age Height Weight Social Security Number

Workers' Compensation Forms and Worksheets. C-Series Forms. C-1 Notice of Injury or Occupational Disease (Incident Report) (2/2020) C-3 Employer's Report of Industrial Injury or Occupational Disease (2/2025) C-4 Employee's Claim for Compensation - Report of Initial Treatment - Fillable (2/2025)

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

In Nevada, a workers' compensation claim begins when a C-4 form is sent to the insurance company that your employer uses for workers' compensation coverage. You will need to fill out your part of the C-4 form the first time you visit a medical provider for treatment of …

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.)

C-1 "NOTICE OF INJURY OR OCCUPATIONAL DISEASE (Incident Report)" form. Notice of Injury or Occupational Disease [C-1 form]

Filing a C-4 form starts a claim. The C-4 form is filled out when you first get medical treatment for your work injury. Medical providers in Nevada are supposed to have C-4 forms available for injured workers.

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.)