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C-4 Doctor's Initial Report Use this form to report the first time you treated the patient. (To report continued treatment, use Form C-4.2. 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. A. Patient's Information 1. Name: - 2. Social Security #: Last First 3. Home phone #: (_____)_______________ 4. WCB Case # (if known): 6. Mailing address: MI - 5. Carrier Case #: Number and Street City 7. Date of injury/onset of illness: ______/______/______ 8. Date of Birth: ______/______/______ 9. Gender: State Zip Code Male Female 10. On the date of injury/illness what was the patient's job title or description: 11. On the date of injury/illness what were the patient's usual work activities:_______________________________________________________ 12. Patient's Account #: B. Employer Information 1. Employer when injury occurred: 2. Phone #: (______)_______________ Company/Agency Name 3. Employer Address: Number and Street City State Zip Code C. Doctor's Information 2. WCB Authorization #: 1. Your name: 3. WCB Rating Code: Last 5. Office address: First MI 4. Federal Tax ID #: The Tax ID # is the (check one): SSN Number and Street City State Zip Code Number and Street City State Zip Code EIN 6. Billing group or practice name: 7. Billing address: 8. Office phone #: (______)_____________ 9. Billing phone #: (______)______________ 10. Treating Provider's NPI #: 11. You are a (check one): Physician Podiatrist Chiropractor D. Billing Information 2. Carrier Code #: W 1. Employer's insurance carrier: 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 on page 2 by line. C-4.0 (10-15) Page 1 of 4 THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.ny.gov Patient's Name: Last First Dates of Service From MM To DD YY MM DD YY Place Leave of Service Blank Date of injury/onset of illness:______/______/______ MI Use WCB Codes Procedures, Services or Supplies CPT/HCPCS Diagnosis Code MODIFIER Check here if services were provided by a WCB preferred provider organization (PPO). Days/ Units $ Charges Total Charge COB Amount Paid (Carrier Use Only) $ $ Zip code where service was rendered Balance Due (Carrier Use Only) $ E. History 1. Based on the patient's history, where and how did the injury/illness happen: 2. How did you learn about the injury/illness (check one): Patient Medical Records Other(specify): 3. Did another health provider treat this injury/illness including hospitalizaton and/or surgery? 4. Have you previously treated this patient for a similar work-related injury/illness? Yes Yes No No If yes, give details: If yes, when: ________________________ F. Exam Information 1. Date(s) of Examination: 2. Patient's subjective complaints: Check all that apply and identify specific affected body part(s). Numbness/Tingling Swelling Pain Weakness Stiffness Other (specify) 3. Type/nature of injury: Check all that apply and identify specific affected body part(s). Abrasion Infectious Disease Amputation Inhalation Exposure Avulsion Laceration Bite Needle Stick Burn Poisoning/Toxic Effects Contusion/Hematoma Psychological Crush Injury Puncture Wound Dermatitis Repetitive Strain Injury Dislocation Spinal Cord Injury Fracture Sprain/Strain Hearing Loss Torn Ligament,Tendon or Muscle Hernia Vision Loss Other (specify) C-4.0 (10-15) Page 2 of 4 www.wcb.ny.gov Patient's Name: Last First Date of injury/onset of illness:______/______/______ MI 4. Physical examination: Check all relevant objective findings and identify specific affected body part(s). None at present Neuromuscular Findings: Bruising Abnormal/Restricted ROM Burns Active ROM Crepitation Passive ROM Deformity Gait Edema Palpable Muscle Spasm Hematoma/Lump/Swelling Reflexes Joint Effusion Sensation Laceration/Sutures Pain/Tenderness Strength (Weakness) Scar Wasting/Muscle Atrophy Other findings:___________________________________________________________________________________________________ 5. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________ 6. Describe any treatment(s) rendered at this visit: ___________________________________________________________________________ 7. Describe prognosis for recovery: _______________________________________________________________________________________ 8. Does the patient's medical history reveal any pre-existing condition(s) that may affect the treatment and/or prognosis? If yes, list and describe: G. Doctor's Opinion 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? Yes No No Yes Yes No N/A (no findings at this time) 4. What is the percentage (0-100%) of temporary impairment? _________% 5. Describe findings and relevant diagnostic test results:______________________________________________________________________ ________________________________________________________________________________________________________________ H. Plan of Care 1. What is your proposed treatment? 2. Medication(s):(a) list medications prescribed: _____________________________________________________________________________ (b) list over-the-counter medications advised:__________________________________________________________________ Medication restrictions: C-4.0 (10-15) Page 3 of 4 None May affect patient's ability to return to work, make patient drowsy, or other issue. Explain below: www.wcb.ny.gov Patient's Name: Last First Date of injury/onset of illness:______/______/______ MI 3. Does the patient need diagnostic tests or referrals? Tests: Yes No If yes, check all that apply: Referrals: CT Scan Chiropractor EMG/NCS Internist/Family Physician MRI (Specify): Occupational Therapist Labs (Specify): Physical Therapist X-rays (Specify): Specialist in Other (Specify): Other (Specify): Cane Crutches Orthotics Walker Wheelchair 4. Assistive devices prescribed for this patient: Other (specify): _______________________________________________________________________________________________ Important: Form C-4 AUTH should be used to request any special medical service costing over $1000 or for those services requiring pre-authorization pursuant to the Medical Treatment Guidelines for the back, neck, knee and shoulder. 5. When is the patient's next follow-up appointment? Within a week 1-2 weeks 3-4 weeks 5-6 weeks months 7-8 weeks Return as needed I. Work Status 1. Has the patient missed work because of the injury/illness? Is the patient currently working? Yes No 2. Can the patient return to work? (check only one): Yes No If yes, date patient first missed work:______/______/______ If yes, did the patient return to: usual work activities limited work activities 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 Climbing stairs/ladders Environmental conditions Kneeling Lifting Operating heavy equipment Operation of motor vehicles Personal protective equipment Sitting Standing Use of public transportation Use of upper extremities Other (explain): Describe/quantify the limitations: How long will these limitations apply? 1-2 days 3-7 days 3. With whom will you discuss the patient's return to work and/or limitations? 8-14 days 15+ days with patient Unknown at this time with patient's employer N/A N/A 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 C-4.0 (10-15) Page 4 of 4 Signature Specialty / Date / www.wcb.ny.gov 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: 48 HOUR INITIAL REPORT - Prepare and submit this form, complete in all details, within 48 hours after you first render treatment. If you continue to treat, use form C-4.2 for future reporting. DO NOT use this form for future reporting. 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. 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 over $1000 or for those services requiring pre-authorization pursuant to the Medical Treatment Guidelines for the back, neck, knee and shoulder. . 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. 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. Ophthalmologists use form C-5, Occupational/Physical Therapists use form OT/PT-4 and Psychologists use form PS-4 for filing reports. AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY 6. 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 Customer Service toll-free number listed 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. IMPORTANTE PARA EL PACIENTE 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. Inquiries, medical and other reports should be sent directly to the Workers' Compensation Board at the address listed below: NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 Customer Service Toll-Free Line: 877-632-4996 C-4.0 (10-15) Statewide Fax Line: 877-533-0337 THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
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