Form C4 2 PDF Details

Form C4 2 is a document used to report the disposition of assets. This form must be filed when certain assets are transferred and provides information about the parties involved in the transfer, as well as the value of the assets transferred. If you need to file a Form C4 2, it's important to understand what is required on the form and how to accurately complete it. In this blog post, we'll walk you through everything you need to know about Form C4 2 so that you can submit it correctly.

Here is the information relating to the file you were seeking to fill out. It will tell you the length of time you will need to complete form c4 2, what fields you will have to fill in and several other specific facts.

QuestionAnswer
Form NameForm C4 2
Form Length3 pages
Fillable?Yes
Fillable fields229
Avg. time to fill out23 min 18 sec
Other namesform c4 4 form, c4 2 pdf, c4 workers comp, wc c4 2

Form Preview Example

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

MI

 

 

 

 

 

 

 

 

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 #:

 

 

 

 

 

 

 

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

 

 

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
No
No

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

No

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)

How to Edit Form C4 2 Online for Free

We were making this PDF editor with the notion of making it as quick to work with as possible. That's why the process of completing the form c4 4 form will undoubtedly be effortless use the next steps:

Step 1: Search for the button "Get Form Here" and hit it.

Step 2: At the moment, you can begin editing your form c4 4 form. Our multifunctional toolbar is at your disposal - insert, eliminate, modify, highlight, and undertake other sorts of commands with the content in the document.

The next parts are contained in the PDF template you will be filling out.

workers compensation c4 2 empty spaces to fill in

Provide the requested data in the field Enter ICD10 Code:, ICD10 Descriptor:, Relate ICD10 codes in (1), Dates of Service, From MM DD YY, MM DD YY, Place of Service, Leave Blank, Use WCB Codes, Procedures, CPT/HCPCS MODIFIER, Diagnosis Code, $ Charges, Days/ Units, and COB.

step 2 to finishing workers compensation c4 2

Put down the necessary information while you're on the Patient's Name:, Last First MI, Date of injury/onset of illness://, Yes, If yes, EMG/NCS, Tests: CT Scan MRI (specify): Labs, Internist/Family Physician, Referrals: Chiropractor, and Important: Form C-4 AUTH should be part.

workers compensation c4 2 Patient

The Within a week, 1-2 wks, 3-4 wks, 5-6 wks, 7-8 wks, months, as needed, Yes Yes, Yes, No No, N/A (no findings at this time), Yes, If yes, Yes, and If yes section is going to be place to include the rights and obligations of either side.

Entering details in workers compensation c4 2 part 4

End up by checking the following sections and filling them in accordingly: I provided the services listed, Provider's name Specialty, Board Authorized Health Care, Name, C-4, Signature, Specialty, / / Date, and www.

step 5 to entering details in workers compensation c4 2

Step 3: Click the Done button to make sure that your finalized file can be exported to any kind of device you use or sent to an email you indicate.

Step 4: You can create copies of the document toprevent all of the forthcoming concerns. You should not worry, we don't publish or monitor your data.

Watch Form C4 2 Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .