Workers Compensation C 4 Form – Fill Out and Use

ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION	C-4
AND CARRIER'S RESPONSE
State of New York - Workers' Compensation Board	AUTH
Answer all questions fully on this report

A. Patient's Name:		Social Security No.:	..................................................
First	MI	Last
Address:
Number and Street	City	State	Zip Code
Employer's Name:
Address:
Number and Street	City	State	Zip Code
Insurance Carrier's Name:
Address:
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.:	..................................................	Fax No.:

The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to the Medical Treatment Guidelines. Do NOT use this form for injuries/illnesses involving the Mid and Low Back, Neck, Knee, and Shoulder; except for the treatment/procedures listed below under Medical Treatment Guideline Procedures Requiring Pre-Authorization. Please use the appropriate Medical Treatment Guideline form if any other procedure/test is being requested.

Medical Treatment Guidelines Procedures Requiring Pre-Authorization (Complete Guideline Reference for each item checked, if necessary. In first box, indicate body part: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines.)

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www.wcb.ny.gov

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 non-emergency situation or requiring pre-authorization pursuant to the Medical Treatment Guidelines.

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 X-ray examinations or physiotherapeutic or other procedures, or to provide for special diagnostic laboratory tests costing more than $1,000.

Podiatrists - In treating the foot, to provide physiotherapeutic procedures, X-ray examinations, or special diagnostic laboratory tests costing more than $1,000.

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 X-ray examinations or physiotherapeutic or other procedures, or to provide for special diagnostic laboratory tests costing more than $1,000.

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 13-a(5) of the Workers' Compensation Law costing more than $1,000 must be requested from the self-insured employer or insurance carrier. In addition, authorization must be requested for any biofeedback treatments, regardless of the cost, or and special diagnostic laboratory tests which may be performed by psychologists. Where a claimant has been referred by an authorized physician to a psychologist for evaluation purposes only and not for treatment, prior authorization must be requested if the cost of consultation exceeds $1,000.

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 self-insured employer, and, if the patient is represented by an attorney or licensed representative, such legal representative. If your patient is not represented, a copy must be sent to your patient.

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, 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.

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 13902-5205

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

STATEWIDE FAX LINE: 877-533-0337

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