Form C 4 PDF Details

Navigating through the landscape of workers' compensation claims can be a complex and daunting task, especially when it involves the meticulous completion of necessary forms. Among these, the Form C-4, or the Employee’s Claim for Compensation/Report of Initial Treatment form, stands out as a crucial document. It serves as a detailed report that must be filled out following an employee’s injury or when an occupational disease arises. This form not only gathers comprehensive information about the injured employee, including their personal information and details about the injury or disease but also includes a section for the medical provider to detail the initial treatment and diagnosis. It is imperative for employees to provide all requested information accurately, as this form plays a critical role in the process of claiming compensation. Furthermore, it carries a certification section where the employee attests to the truthfulness of the provided information and authorizes the release of medical information necessary for processing the claim. The timeliness of this form is also specified, requiring that it be completed and mailed within three working days of treatment, highlighting the procedural diligence required in workers' compensation cases. Form C-4, thus, acts as a linchpin in the process of securing benefits under the relevant industrial insurance and occupational diseases acts, underscoring the importance of its proper and prompt completion.

QuestionAnswer
Form NameForm C 4
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesc 4 form, form c4, nevada c4, c 4 form nevada

Form Preview Example

EMPLOYEE’S CLAIM FOR COMPENSATION/REPORT OF INITIAL TREATMENT

FORM C-4

PLEASE TYPE OR PRINT

EMPLOYEE’S CLAIM – PROVIDE ALL INFORMATION REQUESTED

First Name

M.I.

Last Name

Birthdate

 

Sex

 

Claim Number (Insurer’s Use Only)

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

Home Address

 

 

Age

Height

Weight

 

Social Security Number

 

 

 

 

 

 

 

 

City

State

Zip

Telephone

Mailing Address

City

State

Zip

Primary Language Spoken

INSURER

THIRD-PARTY ADMINISTRATOR

Employee’s Occupation (Job Title) When Injury or Occupational Disease Occurred

Employer’s Name/Company Name

 

 

 

Telephone

 

 

 

 

 

 

 

Office Mail Address (Number and Street)

 

 

 

 

 

 

 

 

 

 

 

Date of Injury (if applicable)

Hours Injury (if applicable)

Date Employer Notified

Last Day of Work After Injury

 

Supervisor to Whom Injury Reported

 

 

 

 

or Occupational Disease

 

 

 

am

pm

 

 

 

 

Address or Location of Accident (if applicable)

 

 

 

 

 

What were you doing at the time of the accident? (if applicable)

How did this injury or occupational disease occur? (Be specific and answer in detail. Use additional sheet if necessary)

If you believe that you have an occupational disease, when did you first have knowledge of the disability and its relationship to your employment?

Witnesses to the Accident (if applicable)

Nature of Injury or Occupational Disease

Part(s) of Body Injured or Affected

I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND THAT I HAVE PROVIDED THIS INFORMATION IN ORDER TO OBTAIN THE BENEFITS OF NEVADA’S INDUSTRIAL INSURANCE AND OCCUPATIONAL DISEASES ACTS (NRS 616A TO 616D, INCLUSIVE OR CHAPTER 617 OF NRS). I HEREBY AUTHORIZE ANY PHYSICIAN, CHIROPRACTOR, SURGEON, PRACTITIONER, OR OTHER PERSON, ANY HOSPITAL, INCLUDING VETERANS ADMINISTRATION OR GOVERNMENTAL HOSPITAL, ANY MEDICAL SERVICE ORGANIZATION, ANY INSURANCE COMPANY, OR OTHER INSTITUTION OR ORGANIZATION TO RELEASE TO EACH OTHER, ANY MEDICAL OR OTHER INFORMATION, INCLUDING BENEFITS PAID OR PAYABLE, PERTINENT TO THIS INJURY OR DISEASE, EXCEPT INFORMATION RELATIVE TO DIAGNOSIS, TREATMENT AND/OR COUNSELING FOR AIDS, PSYCHOLOGICAL CONDITIONS, ALCOHOL OR CONTROLLED SUBSTANCES, FOR WHICH I MUST GIVE SPECIFIC AUTHORIZATION. A PHOTOSTAT OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL.

 

Date

 

Place

 

 

Employee’s Signature

 

 

 

 

 

 

THIS REPORT MUST BE COMPLETED AND MAILED WITHIN 3 WORKING DAYS OF TREATMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place

 

 

 

Name of Facility

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

Diagnosis and Description of Injury or Occupational Disease

Is there evidence that the injured employee was under the influence of alcohol

 

 

 

 

 

 

and/or another controlled substance at the time of the accident?

 

 

 

 

 

 

 

 

No

Yes (if yes, please explain)

 

 

 

 

Hour

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment:

 

 

 

 

Have you advised the patient to remain off work five days or more?

 

 

 

 

 

 

 

 

Yes

Indicate dates: from ____________ to __________________

 

 

 

 

 

 

No

If no, is the injured employee capable of:

full duty

modified duty

 

X-Ray Findings:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If modified duty, specify any limitations/restrictions: _______________________

 

From information given by the employee, together with medical evidence,

can you directly

_________________________________________________________________

 

 

connect this injury or occupational disease as job incurred?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________________________________________

 

 

Is additional medical care by a physician indicated?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you know of any previous injury or disease contributing to this condition or occupational disease?

Yes

No (Explain if yes)

 

 

Date

Print Doctor’s Name

I certify that the employer’s copy of

this form was mailed to the employer on:

Address

INSURER’S USE ONLY

City

State

Zip

Provider’s Tax I.D. Number

Telephone

Doctor’s Signature

Degree

ORIGINAL – TREATING PHYSICIAN OR CHIROPRACTOR

PAGE 2 – INSURER/TPA

PAGE 3 – EMPLOYER

PAGE 4 – EMPLOYEE

Form C-4 (rev.10/07)

How to Edit Form C 4 Online for Free

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It really is straightforward to complete the document with our practical guide! Here is what you need to do:

1. The c4 compensation requires certain information to be inserted. Ensure that the next blank fields are finalized:

Guidelines on how to complete c 4 form nevada stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - I CERTIFY THAT THE ABOVE IS TRUE, THIS REPORT MUST BE COMPLETED AND, Place Name of Facility, Diagnosis and Description of, Is there evidence that the injured, Date, Hour, Treatment, XRay Findings, Have you advised the patient to, cid Yes Indicate dates from to, cid No If no is the injured, If modified duty specify any, From information given by the, and Is additional medical care by a with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Find out how to prepare c 4 form nevada stage 2

People often make some mistakes while filling out THIS REPORT MUST BE COMPLETED AND in this part. You should definitely re-examine what you enter right here.

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