Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it.

Forms are in PDF format. The Board recommends using the latest version of Adobe Reader which is available as a free download from Adobe's website. After the form opens, you may complete the form by typing information on the form before you print it.

This form is to be used to file reports in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit cases as follows: 48 HOUR INITIAL REPORT - Prepare and submit this form, complete in all details, within 48 hours after you first render treatment.

* Complete and attach Release of Information (Form C-4A) when injured employee signs C-4 Form electronically ORIGINAL – TREATING HEALTHCARE PROVIDER Form CPAGE 2 – INSURER/TPA PAGE 3 – EMPLOYER PAGE 4 – EMPLOYEE -4 (rev.08/21)

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.

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 requiring pre-authorization pursuant to the Medical Treatment Guidelines.

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)