Are you required to submit a workers compensation C 4 form? What is it, and what information does it include? In this blog post, we'll provide an overview of the workers compensation C 4 form and explain why it's important. We'll also help you understand what happens if you fail to submit this document.
Below is the information regarding the form you were looking for to complete. It can show you the time it should take to complete workers compensation c 4 form, exactly what fields you need to fill in and a few other specific facts.
Question | Answer |
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Form Name | Workers Compensation C 4 Form |
Form Length | 3 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 45 sec |
Other names | worker comp c4 form, nys workers compensation forms c4, c4 auth and mg2 forms, ny workers comp c 4 2 form |
ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION |
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AND CARRIER'S RESPONSE |
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State of New York - Workers' Compensation Board |
AUTH |
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Answer all questions fully on this report |
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WCB Case Number: |
Carrier Case Number: |
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Date of Injury:
A. Patient's Name: |
Social Security No.: |
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First |
MI |
Last |
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Address: |
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Number and Street |
City |
State |
Zip Code |
Employer's Name: |
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Address: |
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Number and Street |
City |
State |
Zip Code |
Insurance Carrier's Name: |
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Address: |
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Number and Street |
City |
State |
Zip Code |
B.Attending Doctor's Name:
Address: ............................................................................................................................................................................................................................................................................................................................................................................................................................................
Number and Street |
City |
State |
Zip Code |
Provider's Authorization No.: |
Telephone No.: |
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Fax No.: |
C.
AUTHORIZATION REQUEST
The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring
Authorization Requested:
Diagnostic Tests:
Radiology Services
Other
Therapy (including Post Operative): |
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Physical Therapy: |
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times per week for |
weeks |
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OccupationalTherapy: |
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times per week for |
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Other
Surgery:
Type of Surgery (Describe, include use of hardware/surgical implants)
Treatment:
Other
Carrier Response: if any service is denied, explain on reverse.
Granted |
Granted w/o Prejudice |
Denied |
Granted |
Granted w/o Prejudice |
Denied |
Granted |
Granted w/o Prejudice |
Denied |
Granted |
Granted w/o Prejudice |
Denied |
Granted |
Granted w/o Prejudice |
Denied |
Granted |
Granted w/o Prejudice |
Denied |
Granted |
Granted w/o Prejudice |
Denied |
Granted |
Granted w/o Prejudice |
Denied |
Medical Treatment Guidelines Procedures Requiring
1. |
Lumbar Fusions |
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1. |
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2. Artificial Disk Replacement |
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- |
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E |
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2. |
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3. |
Vertebroplasty |
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B |
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E |
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7 |
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a |
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3. |
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4. Kyphoplasty |
B |
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E |
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7 |
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4. |
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5. |
Electrical Bone Growth Stimulators |
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E |
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5. |
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6. |
Spinal Cord Stimulators |
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B |
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................................................................. |
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6. |
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7. |
Osteochondral Autograft |
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K |
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D |
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1 |
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f |
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7. |
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8. Autologus Chondrocyte Implantation |
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K |
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D |
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8. |
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9. Meniscal Allograft Transplantation |
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K |
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D |
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................................................. |
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9. |
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10. Knee Arthroplasty (total or partial knee joint replacement) |
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K |
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F |
2 |
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............10. |
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11. Second or Subsequent Procedure |
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................................................ |
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11. |
Granted
Granted
Granted
Granted
Granted
Granted
Granted Granted
Granted
Granted
Granted
Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice
Granted w/o Prejudice Granted w/o Prejudice
Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice
Denied
Denied
Denied
Denied
Denied
Denied
Denied Denied
Denied
Denied
Denied
www.wcb.ny.gov |
STATEMENT OF MEDICAL NECESSITY
Pursuant to 12 NYCRR
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Date of service of supporting medical in WCB Case File: |
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(If not already in file, supporting medical must be attached.) |
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I certify that I am making the above request for authorization. This request was made to the insurance |
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A. By fax on (date) |
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to (person contacted) |
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B. By telephone on (date) |
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to (person contacted) |
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and |
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A copy of this form was sent to the Board on the date below. |
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Provider's Signature: |
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Date: |
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D. |
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Response Time and Notification Required: |
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The |
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delivery within 30 days. The 30 day time period for response begins to run from the completion date of this form if |
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completion date plus five days if sent via regular mail. The written response shall be on a copy of this form completed by the physician seeking |
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authorization and shall clearly state whether the authorization has been granted, granted without prejudice, or denied. Authorization can only be |
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granted without prejudice when the compensation case is controverted or the body part has not yet been established. Authorization without |
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prejudice shall not be construed as an admission that the condition for which these services are required is compensable or the employer/carrier |
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is liable. The employer/carrier shall not be responsible for the payment of such services until the question of compensability and liability is |
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resolved. Written response must be sent to the health care provider, claimant, claimant's legal counsel, if any, the Workers' Compensation Board |
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and any other parties of interest. |
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Denial of the Request for Authorization of a Special Service: A denial of authorization of a special service must be based upon and |
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accompanied by a conflicting second opinion rendered by a physician authorized to conduct IMEs, or record review, or qualified medical |
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professional, or a physician authorized to treat workers' compensation claimants. (If authorization is denied in a controverted case, the conflicting |
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second opinion must address medical necessity only.) When denying authorization for a special service, the employer/carrier must also file with |
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the Board within 5 days of such denial Board Form |
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conflicting second opinion and Board Form |
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failure to attend an IME examination scheduled within the 30 day authorization period, contemporaneous supporting evidence of claimant's failure |
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must be attached. |
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Failure to Timely Respond to |
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Order of the Chair if the |
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appeal under Section 23 of the Workers' Compensation Law. |
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REASON FOR DENIAL(S), IF ANY. (ATTACH OR REFERENCE CONFLICTING SECOND MEDICAL OPINION AS EXPLAINED ABOVE.) |
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Date of service of supporting medical in WCB case file:
I certify that the
and
I certify that copies of this form were
By: (print name) |
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Title: |
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Signature: |
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Date: |
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www.wcb.ny.gov |
REQUEST FOR WRITTEN AUTHORIZATION
IMPORTANT TO ATTENDING DOCTOR
AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY
1.This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case as follows: To confirm a telephone request for written authorization for special service(s) costing over $1,000 in a
2.SPECIAL SERVICES - Services for which authorization must be requested are as follows:
Physicians - To engage the services of a specialist, consultant, or a surgeon, or to provide for
Podiatrists - In treating the foot, to provide physiotherapeutic procedures,
Chiropractors - In treating a condition as provided in Section 6551 of the Education Law, to engage the services of a specialist, consultant, or a surgeon, or to provide for
Occupational/Physical Therapists - In treating a condition as provided in Article 136 or 156 of the Education Law, in the Workers' Compensation Law, and the Rules of the Chair relative to Occupational/Physical Therapy Practice to provide occupational/physical therapy procedures costing more than $1,000.
Psychologists - Prior authorization for procedures enumerated in section
Medical Treatment Guidelines - Lumbar Fusions, Artificial Disk Replacement, Vertebroplasty, Kyphoplasty, Electrical Bone Growth Stimulators, Spinal Cord Stimulators, Osteochondral Autograft, Autologus Chondrocyte Implantation, Meniscal Allograft Transplantation, Knee Arthroplasty (total or partial knee joint replacement).
3.When requesting authorization over the telephone, be sure to obtain the name of the person contacted since you must indicate this information along with the date of contact and certify its validity on the form.
4.It is the attending physician's burden to set forth the medical necessity of the special services required. Be sure to provide this information in the Statement of Medical Necessity section of this form.
5.This form must be signed by the attending doctor and must contain her/his authorization certificate number and code letters. 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.
6.Please ask your patient for his/her WCB case number and the carrier's case number and show these numbers on this form. In addition, ask your patient if he/she has retained a representative. If represented, ask for the name and address of the representative.
This request must be sent to the Workers' Compensation Board, the workers' compensation insurance carrier or
7.If authorization or denial is not forthcoming within 30 calendar days, notify the nearest office of the Workers' Compensation Board.
8.HIPAA NOTICE - In order to adjudicate a workers' compensation claim,
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
Reports should be filed by sending directly to the Workers' Compensation Board at the address below with a copy sent to the insurance carrier:
NYS Workers' Compensation Board
Centralized Mailing
PO Box 5205
Binghamton, NY
Customer Service
STATEWIDE FAX LINE:
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION |