Fce 4 Form PDF Details

In the complex and evolving landscape of workers' compensation within New York State, the Form FCE-4 stands as a pivotal document, bridging the critical gap between medical assessment and vocational rehabilitation. This Practitioner's Report of Functional Capacity Evaluation is fundamental to ensuring fair and accurate representation of an injured worker's physical and occupational capabilities following a work-related injury. Designed meticulously to collect comprehensive data, the form serves multiple stakeholders, including the Workers' Compensation Board, insurance carriers, attorneys, and most importantly, the injured workers themselves. Its primary aim is to objectively evaluate an individual's ability to perform work-related tasks at a point of maximum medical improvement, thus facilitating decisions regarding return to work, need for job modifications, or further therapeutic interventions. By requiring the attending physician to detail any restrictions or limitations, and mandating transparency in the reporting process to deter fraudulent practices, the form underscores the commitment to integrity and accuracy in the workers' compensation system. Moreover, it highlights the eligibility criteria for undergoing such examination, specifying the conditions under which it can be prescribed and reiterating the role of standardized evaluation tools in determining a claimant's suitability for resuming vocational activities. In essence, the FCE-4 form embodies a critical step towards achieving a balance between the healthcare and vocational reintegration needs of injured workers, aligning medical evaluations with practical, employment-related outcomes.

QuestionAnswer
Form NameFce 4 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmg2 form 2019, mg2 form workers comp, mg2 form ny workers comp, mg2 forms doctors request for approval variance and insurers response

Form Preview Example

STATE OF NEW YORK - WORKERS' COMPENSATION BOARD

PRACTITIONER'S REPORT OF FUNCTIONAL CAPACITY EVALUATION

All reports are to be filed with the Workers' Compensation Board (see address on reverse), the workers' compensation insurance carrier, and if the patient is represented by an attorney or licensed representative, with such representative. If the patient is not represented, a copy must be sent to the patient.

THIS EXAMINATION WAS REQUESTED BY:

CARRIER/EMPLOYER

ATTENDING PHYSICIAN

DATE ATTENDING PHYSICIAN FOUND THAT CLAIMANT ACHIEVED MAXIMUM MEDICAL IMPROVEMENT ___________________ . ATTENDING PHYSICIAN MUST

SET FORTH, IN WRITING, ANY RESTRICTIONS OR LIMITATIONS THAT THE CLAIMANT HAS WITH REFERENCE TO THE FUNCTIONAL CAPACITY EXAMINATION. IF NONE, THE ATTENDING PHYSICIAN MUST INDICATE SO. ATTACH SUPPORTING DOCUMENTATION.

WCB CASE NO.

CARRIER CASE NO. (IF KNOWN)

DATE OF INJURY

INJURED PERSON'S SOCIAL SECURITY NUMBER

DATE OF EXAMINATION

INJURED

(First Name)

(Middle Initial)

(Last Name)

ADDRESS (Include Apt. No.)

 

 

 

 

PERSON

 

 

 

 

EMPLOYER

INSURANCE

CARRIER

The following eligibility criteria are required (check one):

a. Claimant is preparing to return to a previous job, or

b. Claimant has been offered a new job (verified), or

c. Claimant is working with a rehabilitation provider and a vocational objective is established.

If an entity other than the Employer/Carrier or Attending Physician has arranged for the Functional Capacity Examination, please indicate the entity's name and address.

Results of Examination (attach additional sheets, if necessary)

I hereby certify that the claimant meets all of the requirements as indicated on the reverse of this form and this report is a full and truthful representation of my professional opinion with respect to the claimant's condition.

__________________________________________________________

__________________________________________________________

Practitioner's Name

Practitioner's Signature

__________________________________________________________

__________________________________________________________

Practitioner'sLicense Number

Date

NO PRACTITIONER EXAMINING OR EVALUATING A CLAIMANT UNDER THE WORKERS' COMPENSATION LAW NOR ANY SUPERVISING AUTHORITY OR PROPRIETOR NOR INSURANCE CARRIER OR EMPLOYER MAY CAUSE, DIRECT OR ENCOURAGE A REPORT TO BE SUBMITTED AS EVIDENCE IN WORKERS` COMPENSATION CLAIM ADJUDICATION WHICH DIFFERS SUBSTANTIALLY FROM THE PROFESSIONAL OPINION OF THE EXAMINING PRACTITIONER. SUCH AN ACTION SHALL BE CONSIDERED WITHIN THE JURISDICTION OF THE WORKERS` COMPENSATION FRAUD INSPECTOR GENERAL AND MAY BE REFERRED AS A FRAUDULENT PRACTICE.

FCE-4 (1-11)

NEW YORK WORKERS' COMPENSATION PHYSICAL MEDICINE FEE SCHEDULE

14.FUNCTIONAL CAPACITY EVALUATIONS Indications

The FCE is utilized for the following purposes:

1.To determine the level of safe maximal function at the time of maximum medical improvement.

2.To provide a pre-vocational baseline of functional capabilities to assist in the vocational rehabilitation process.

3.To objectively set restrictions and guidelines for return to work.

4.To determine whether specific job tasks can be safely performed by modification of technique, equipment, or by further training.

5.To determine whether additional treatment or referral to a work hardening program is indicated.

6.To assess outcome at the conclusion of a work hardening program.

General Requirements

1.The FCE may be prescribed only by a licensed physician in NYS, or may be requested by the carrier when indicated.

2.The FCE does not require prior authorization by the carrier.

3.The attending physician must justify the indication for each at the request of the carrier (see Eligibility Criteria).

4.The FCE shall be performed by a physical or occupational therapist currently holding a valid license in NYS, or other licensed provider qualified by scope of practice. Constant supervision by the licensed provider is required.

Specific Requirements

1.The FCE, when medically necessary and indicated, may be performed only at the point of maximum medical improvement in the opinion of the attending physician.

2.The FCE should not be prescribed prior to three (3) months post-injury unless there is a significant documented change in the claimant's status which justified earlier utilization.

3.The following eligibility criteria is required for all claimants:

a.Claimant is preparing to return to previous job.

b.Claimant has been offered a new job (verified).

c.Claimant is working with a rehabilitation provider and a vocational objective is established.

4.Reports will include the following information:

a.Patient demographics including work history.

b.Indication for evaluation.

c.Type of evaluation performed.

d.Raw and tabulated data.

e.Normative date values.

f.Narrative cover sheet with recommendations.

5.The bill for services provided must be attached to the report to be processed by the carrier.

6.All evaluation tools must be standardized, and normative data and interpretive guidelines must be attached to the report.

7.Charges for psychometric testing performed as part of the FCE by providers other than psychologists or psychiatrists are inclusive and may not be billed separately.

8.Testing and/or treatment provided by licensed psychologists or psychiatrists must be performed in accordance with the Psychology or Medicine fee schedules, and should be billed separately.

HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.

All reports should be sent directly to the Workers' Compensation Board at the address listed below:

NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205

Customer Service Toll-Free Line: 877-632-4996

Statewide Fax Line: 877-533-0337

FCE-4 Reverse (1-11)

www.wcb.ny.gov

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

How to Edit Fce 4 Form Online for Free

If you wish to fill out mg2 form ny workers comp, you don't have to download and install any applications - just give a try to our PDF tool. The tool is continually updated by our staff, receiving handy functions and turning out to be greater. To get the process started, take these basic steps:

Step 1: Firstly, open the editor by clicking the "Get Form Button" above on this page.

Step 2: As soon as you access the online editor, you will see the form prepared to be filled out. Apart from filling in different blanks, you may also perform other actions with the form, that is putting on custom text, changing the original text, inserting graphics, signing the form, and more.

Be attentive while filling in this document. Ensure that each blank field is done correctly.

1. The mg2 form ny workers comp requires particular details to be inserted. Make sure the subsequent blank fields are completed:

Writing part 1 in mg 2 workers comp form

2. After the last segment is completed, you're ready add the necessary specifics in I hereby certify that the claimant, Practitioners Name, Practitioners Signature, Practitioners License Number, Date, NO PRACTITIONER EXAMINING OR, and FCE so that you can go further.

Date, Practitioners Signature, and NO PRACTITIONER EXAMINING OR inside mg 2 workers comp form

Be very careful while completing Date and Practitioners Signature, as this is the part where a lot of people make mistakes.

Step 3: Reread everything you have entered into the blank fields and click on the "Done" button. Join us right now and immediately access mg2 form ny workers comp, set for download. All adjustments you make are kept , making it possible to edit the document further when necessary. Whenever you work with FormsPal, you can complete forms without being concerned about personal information leaks or entries getting distributed. Our protected system ensures that your personal information is maintained safe.