Form C4 2 – Fill Out and Use This PDF

The C4 2 form, or Doctor's Progress Report, is a crucial document used by physicians to report ongoing services for a patient in the context of a workers' compensation case. This form should be submitted after the initial treatment report (Form C-4) and is essential for updating the Workers' Compensation Board, insurance carriers, and any legal representatives about the patient's current condition, further treatments, and progress. It's vital for ensuring that patients receive timely treatment and wage loss benefits, as well as for documenting any changes that might affect the patient's recovery or compensation. Ensure prompt and complete filling out of the form by clicking the button below.

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Form C4 2 PDF Details

The Doctor's Progress Report C-4.2 serves a crucial function in the workers' compensation process, enabling healthcare providers to document and report on the ongoing treatment of injured workers. Unlike the initial report captured by Form C-4 or the documentation of permanent impairment required by Form C-4.3, the C-4.2 form focuses on the continuation of medical services provided to the patient. Healthcare providers are tasked with thoroughly answering all questions and, if necessary, attaching additional pages to ensure comprehensive documentation. Timely submission of this form to the Board, insurance carrier, and, if applicable, the patient's attorney or licensed representative is emphasized as critical. Delays in submission can inadvertently hinder the payment for necessary treatments, delay wage loss benefits, necessitate further testimony, and potentially risk the provider's authorization by the Board. The form also highlights the importance of including detailed billing information, diagnostic tests conducted, changes in treatment plans, and assessments of the patient's work capabilities. Significantly, the form includes provisions for providers to indicate whether the patient's condition and treatment align with their medical opinions regarding the injury's causation and the patient's capacity to resume work, underscoring the integral role of medical assessment in the trajectory of workers' compensation claims. Compliance with these reporting requirements is not just a matter of administrative procedure; it is integral to the fair and efficient functioning of the workers' compensation system, ensuring that injured workers receive the timely and appropriate medical care and benefits they are entitled to.

Question	Answer
Form Name	Form C4 2
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	c 4 2, c42 form, workers comp c 4, wc c4 2

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Doctor's Progress Report

C-4.2

Use this form to report continuing services. (To report the first time you treated the patient, use Form C-4. To report permanent impairment, use Form C-4.3.)

Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www. wcb.ny.gov.

Date(s) of Examination: ______________________________________________________________________________________________

WCB Case Number (if known):Carrier Case Number (if known):

A. Patient's Information

1. Name:

2. Date of injury/illness: _____/_____/_____ 3. Soc. Sec. #:

Last

First

4. Address (if changed from previous report):

Number and Street

City

State

Zip Code

5.Patient's Account #:

B.Doctor's Information

1.Your name:

3.WCB Rating Code:

5.Office address:

Last		First	MI		2. WCB Authorization #:
Last		First	MI
		4. Federal Tax ID #:		The Tax ID # is the (check one ):

	Number and Street		City			State

SSN EIN

Zip Code

6.Billing Group or Practice Name:

7.Billing address:

Number and Street

8. Office phone #: (______)_____________ 9. Billing phone #: (______)______________

City	State	Zip Code
City

10. Treating Provider's NPI #:

C. Billing Information

1. Employer's insurance carrier:

2. Carrier Code #: W

3. Insurance carrier's address:

Number and Street

City

State

Zip Code

4. Diagnosis or nature of disease or injury:

Enter ICD10 Code:

ICD10 Descriptor:

(1)

(2)

(3)

(4)

Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column below by line.

		Dates of Service
From			To
MM	DD	YY	MM DD	YY

Place of Service

Leave Blank

Use WCB Codes

Procedures, Services or Supplies

CPT/HCPCS MODIFIER

Diagnosis Code

$ Charges

Days/

Units

COB

Zip code where service

was rendered

Check here if services were provided by a WCB preferred provider organization (PPO).

D. Examination and Treatment

Total Charge

Amount Paid (Carrier Use Only)

Balance Due (Carrier Use Only)

1. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________

C-4.2 (10-15) Page 1 of 2		www.wcb.ny.gov

Yes Yes

Patient's Name:				Date of injury/onset of illness:______/______/______
	Last	First	MI

2.List any changes revealed by your most recent examination in the following: area of injury, type/nature of injury, patient's subjective complaints

or your objective findings: _____________________________________________________________________________________________

3.List additional body parts affected by this injury, if any: ______________________________________________________________________

4.Based on your most recent examination, list changes to the original treatment plan, prescription medications or assistive devices, if any:

5. Based on this examination, does the patient need diagnostic tests or referrals?			Yes	No	If yes, check all that apply:
Tests:		Referrals:
CT Scan	EMG/NCS	Chiropractor			Internist/Family Physician
MRI (specify):		Occupational Therapist
Labs (specify):		Physical Therapist
X-rays (specify):		Specialist in:

Other (specify):		Other (specify):

Important: Form C-4 AUTH should be used to request any special medical service over $1000 or for those services requiring pre-authorization pursuant to the Medical Treatment Guidelines for the back, neck, knee and shoulder.

6. Describe treatment rendered today:

7. When is patient's next follow-up visit?

Within a week

1-2 wks

3-4 wks

5-6 wks

7-8 wks

____ months

as needed

E. Doctor's Opinion (based on this examination)

1. In your opinion, was the incident that the patient described the competent medical cause of this injury/illness? 2. Are the patient's complaints consistent with his/her history of the injury/illness?

Yes

3.Is the patient's history of the injury/illness consistent with your objective findings?

4.What is the percentage (0-100%) of temporary impairment? ______________%

N/A (no findings at this time)

5.Describe findings and relevant diagnostic test results:_______________________________________________________________________

_________________________________________________________________________________________________________________

F.Return to Work


1. Is patient working now?			Yes	No	If yes, are there work restrictions?		Yes	No If yes, describe the work restrictions:

	How long will the work restrictions apply?				1-2 days	3-7 days	8-14 days	15+ days	Unknown at this time
2. Can patient return to work? (check only one)
	a.	The patient cannot return to work because (explain):

b. The patient can return to work without limitations on: _______/_______/_______

c. The patient can return to work with the following limitations (check all that apply) on: _______/_______/_______


Bending/twisting		Lifting				Sitting
Climbing stairs/ladders		Operating heavy equipment				Standing
Environmental conditions		Operation of motor vehicles				Use of public transportation
Kneeling		Personal protective equipment				Use of upper extremities
Other (explain):
Describe/quantify the limitations:
How long will these limitations apply?	1-2 days	3-7 days	8-14 days		15+ days	Unknown at this time	N/A
3. With whom will you discuss the patient's returning to work and/or limitations?				with patient		with patient's employer	N/A
4. Would the patient benefit from vocational rehabilitation?		Yes	No
This form is signed under penalty of perjury.
Board Authorized Health Care Provider - Check one:

I provided the services listed above.
I actively supervised the health-care provider named below who provided these services.
	Provider's name___________________________________________________ Specialty__________________________________
Board Authorized Health Care Provider signature:
			/	/
Name		Signature	Specialty	Date

C-4.2 (10-15) Page 2 of 2		www.wcb.ny.gov

IMPORTANTE PARA EL PACIENTE

MEDICAL REPORTING

IMPORTANT - TO THE ATTENDING DOCTOR

1.This form is to be used to file reports in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit cases as follows:

PROGRESS REPORTS - Following the filing of Form C-4, Doctor's Initial Report, file this form within 15 days after initial report and thereafter during continuing treatment without further request, when a follow-up visit is necessary, except the intervals between reports shall be no more than 90 days.

When reporting on MMI and/or Permanent Impairment, use Form C-4.3.

All reports are to be filed with the Workers' Compensation Board, the workers' compensation insurance carrier, self-insured employer, and if the patient is represented by an attorney or licensed representative, with such representative. If the claimant is not represented, a copy must be sent to the claimant.

Ophthalmologists use Form C-5, Occupational/Physical Therapists use Form OT/PT-4 and Psychologists use Form PS-4 for filing reports.

2.Please ask your patient for his/her WCB Case Number and the Insurance Carrier's Case Number, if they are known to him/her, and show these numbers on your reports. In addition, ask your patient if he/she has retained a representative. If so, ask for the name and address of the representative. You are required to send copies of all reports to the patient's representative, if any.

3.This form must be signed by the attending doctor and must contain her/his authorization certificate number, code letters and NPI number. If the patient is hospitalized, it may be signed by a licensed doctor to whom the treatment of the case has been assigned as a member of the attending staff of the hospital.

4.AUTHORIZATION FOR SPECIAL SERVICES - Form C-4 AUTH should be used to request any special medical service(s) costing over $1000 or for those services requiring pre-authorization pursuant to the Medical Treatment Guidelines for the back, neck, knee or shoulder.

AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY

5.LIMITATION OF PODIATRY TREATMENT - Podiatry treatment is limited as defined in Section 7001 of the Education Law and Section 13-k(2) of the Workers' Compensation Law.

6.LIMITATION OF CHIROPRACTIC TREATMENT - Chiropractic treatment is limited as defined in Section 6551 of the Education Law and the Chair's Rules Relative to Chiropractic Practice Under Section 13-l of the Workers' Compensation Law.

A CHIROPRACTOR OR PODIATRIST FILING THIS REPORT CERTIFIES THAT THE INJURY DESCRIBED CONSISTS SOLELY OF A CONDITION(S) WHICH MAY LAWFULLY BE TREATED AS

DEFINED IN THE EDUCATION LAW AND, WHERE IT DOES NOT, HAS ADVISED THE INJURED PERSON TO CONSULT A PHYSICIAN OF HIS/HER CHOICE.

7.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.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

BILLING INFORMATION

Complete all billing information contained on this form. Use continuation Form C-4.1, if necessary. The workers' compensation carrier has 45 days to pay your bill or to file an objection to it. Contact the workers' compensation carrier if you receive neither payment nor an objection within this time period. After contacting the carrier, you may, if necessary, contact the Board's Disputed Bill Unit, at the Albany address indicated below, for information/assistance.

IMPORTANT TO THE PATIENT

YOUR DOCTORS' BILLS (AND BILLS FOR HOSPITALS AND OTHER SERVICES OF A MEDICAL NATURE) WILL BE PAID BY YOUR EMPLOYER, THE LIABLE POLITICAL SUBDIVISION OR ITS INSURANCE COMPANY OR THE UNAFFILIATED VOLUNTEER AMBULANCE SERVICE IF YOUR CLAIM IS ALLOWED. DO NOT PAY THESE BILLS YOURSELF, UNLESS YOUR CASE IS DISALLOWED OR CLOSED FOR FAILURE TO PROSECUTE.

IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE OR YOUR CASE, OR WITH RESPECT TO YOUR RIGHTS UNDER THE WORKERS' COMPENSATION LAW, OR THE VOLUNTEER FIREFIGHTERS' OR VOLUNTEER AMBULANCE WORKERS' LAWS, YOU SHOULD CONSULT THE NEAREST OFFICE OF THE BOARD FOR ADVICE. ALWAYS USE THE CASE NUMBERS SHOWN ON THE OTHER SIDE OFTHIS NOTICE, OR ON OTHER PAPERS RECEIVED BY YOU, IF YOU FIND IT NECESSARY TO COMMUNICATE WITH THE BOARD OR THE CARRIER. ALSO, MENTION YOUR SOCIAL SECURITY NUMBER IF YOU WRITE OR CALL THE BOARD.

LAS FACTURAS POR SERVICIOS MEDICOS INCLUYENDO HOSPITALES Y TODO SERVICIO DE NATURALEZA MEDICA SERA PAGADO POR EL PATRONO O POR LA ENTIDAD RESPONSABLE O SU COMPANIA DE SEGUROS SEGUN SEA EL CASO; SI SU RECLAMACION ES APROBADA. NO PAGUE ESTAS FACTURAS A MENOS QUE SU CASO SEA DESESTIMADO EN SU FONDO O ARCHIVADO POR NO REALIZAR LOS TRAMITES CORRESPONDIENTES.

SI USTED TIENE ALGUNA PREGUNTA, EN RELACION A ESTA NOTIFICACION O A SU CASO O EN RELACION A SUS DERECHOS BAJO LA LEY DE COMPENSACION OBRERA O LA LEY DE BOMBEROS VOLUNTARIOS O LA LEY DE SERVICIOS DE AMBULANCIAS VOLUNTARIOS DEBE COMUNICARSE CON LA OFICINA MAS CERCANA DE LA JUNTA PARA ORIENTACION. SIEMPRE USE EL NUMERO DEL CASO QUE APARECE EN LA PARTE DEL FRENTE DE ESTA NOTIFICACION, O EN OTROS DOCUMENTOS RECIBIDOS POR USTED. SI LE ES NECESARIO COMUNICARSE CON LA JUNTA O CON EL "CARRIER."

TAMBIEN MENCIONE EN SU COMUNICACION ORAL O ESCRITA SU NUMERO DE SEGURO SOCIAL.

WORKERS' COMPENSATION BOARD

Reports should be filed by sending directly to the WCB at the address below with a copy sent to the insurance carrier:

NYS Workers' Compensation Board

Centralized mailing

PO Box 5205

Binghamton, NY 13902-5202

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

Statewide Fax Line: 877-533-0337

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

C-4.2 (10-15)

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Step 1: Look for the button "Get Form Here" on the following site and next, click it.

Step 2: When you enter the c4 2 form editing page, you will see lots of the functions you can undertake regarding your document within the upper menu.

Prepare the c4 2 form PDF by entering the data needed for each individual part.

entering details in c4 2 workers comp step 1

Put the demanded details in the Employers insurance carrier, Insurance carriers address, Number and Street, City, State, Zip Code, Carrier Code W, Enter ICD Code, ICD Descriptor, Relate ICD codes in or to, Dates of Service, From MM DD YY, MM DD YY, Place of Service, and Leave Blank field.

c4 2 workers comp Employers insurance carrier, Insurance carriers address, Number and Street, City, State, Zip Code, Carrier Code W, Enter ICD Code, ICD Descriptor, Relate ICD codes in or to, Dates of Service, From MM DD YY, MM DD YY, Place of Service, and Leave Blank fields to fill

Within the segment talking about Check here if services were, D Examination and Treatment, Total Charge, Amount Paid Carrier Use Only, Balance Due Carrier Use Only, Describe any diagnostic tests, C Page of, and wwwwcbnygov, you have got to note some required information.

stage 3 to entering details in c4 2 workers comp

The Patients Name, Last First MI, Date of injuryonset of illness, List any changes revealed by your, List additional body parts, Based on your most recent, Based on this examination does, Yes, If yes check all that apply, EMGNCS, Tests CT Scan MRI specify Labs, InternistFamily Physician, Referrals Chiropractor, Important Form C AUTH should be, and Describe treatment rendered today section is the place to put the rights and obligations of all parties.

Check the areas E Doctors Opinion based on this, In your opinion was the incident, Yes Yes, No No, Yes, NA no findings at this time, What is the percentage of, Describe findings and relevant, F Return to Work Is patient, Yes, If yes are there work restrictions, Yes, If yes describe the work, How long will the work, and days and next fill them in.

c4 2 workers comp E Doctors Opinion based on this, In your opinion was the incident, Yes Yes, No No, Yes, NA no findings at this time, What is the percentage of, Describe findings and relevant, F Return to Work Is patient, Yes, If yes are there work restrictions, Yes, If yes describe the work, How long will the work, and days blanks to fill

Step 3: Press "Done". Now you may export the PDF file.

Step 4: To stay away from potential upcoming concerns, ensure you possess at the very least a few copies of each separate document.

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