C 4 3 Form – Fill Out and Use This PDF

C 4 3 Form PDF Details

What Is the C-4.3 Form?

The C-4.3 form, formally titled the Doctor’s Report of MMI/Permanent Partial Impairment, is an official New York Workers Compensation Board document. Treating physicians complete this form to document a patient’s medical status after a work-related injury or illness. The report certifies whether the patient has reached Maximum Medical Improvement (MMI) and whether any permanent partial impairment remains. Insurance carriers, the Workers Compensation Board, and legal representatives all rely on this report when evaluating workers compensation claims and determining the level of benefits the patient receives.

Who Must Complete the C-4.3 Form?

A licensed treating physician, surgeon, or other authorized medical professional completes the C-4.3 form. The doctor must examine the patient and make a formal determination about MMI status. Maximum Medical Improvement is the point at which the patient’s condition has stabilized and further recovery is not expected with additional medical treatment. If permanent partial impairment is found, the physician must assess the affected body parts and assign impairment ratings according to New York Workers Compensation Board guidelines. These ratings have a direct bearing on compensation payments.

Key Sections of the C-4.3 Form

The form is organized into sections that together provide a complete picture of the patient’s workers compensation case:

• Billing Information: The doctor enters CPT billing codes, charges, the employer’s insurance carrier, the carrier code, and address details needed for the insurance claim.
• Patient and Claim Data: Records the patient’s name, date of birth, date of injury, and workers compensation claim number. Accurate information here ensures the report is matched to the correct insurance file.
• MMI Determination: The doctor certifies whether the patient has reached Maximum Medical Improvement. If yes, the MMI date is entered. If no, the physician must explain why the patient has not yet reached that milestone.
• Permanent Partial Impairment: If permanent partial impairment exists, the doctor lists each affected body part and provides a percentage impairment rating. These ratings directly determine the compensation payments the patient receives.
• Physician Signature: The form is signed under penalty of perjury. The doctor provides their name, medical specialty, and signature to certify that all information in the report is accurate.

Timely and accurate submission to the insurance carrier, the Workers Compensation Board, and the patient’s attorney is critical. Delays or incomplete data can result in postponed compensation and additional legal review. For earlier stages of the claim, see the Workers Compensation C-4 Form and the C-4.2 Progress Report Form.