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User Manual: C)(S
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5. Carrier Case #:
4. WCB Case # (if known):
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.)
4. Diagnosis or nature of disease or injury:
Enter ICD10 Code:
ICD10 Descriptor:
(1)
(2)
(3)
(4)
D. Billing Information
Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column on page 2 by line.
1. Employer's insurance carrier:
3. Insurance carrier's address:
Zip Code
State
City
Number and Street
C-4
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.
8. Date of Birth: ______/______/______
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:_______________________________________________________
Female
Male
9. Gender:
2. Social Security #:
1. Name:
3. Home phone #: (_____)_______________
6. Mailing address:
7. Date of injury/onset of illness: ______/______/______
A. Patient's Information
Zip Code
State
City
Number and Street
Last First MI
- -
Number and Street
3. Employer Address:
1. Employer when injury occurred:
B. Employer Information
Zip Code
State
City
Company/Agency Name
2. Phone #: (______)_______________
Number and Street
3. WCB Rating Code:
1. Your name:
2. WCB Authorization #:
8. Office phone #: (______)_____________
SSN
EIN
Number and Street
5. Office address:
City
7. Billing address:
State
Zip Code
10. Treating Provider's NPI #:
4. Federal Tax ID #:
C. Doctor's Information
The Tax ID # is the (check one):
Zip Code
State
City
Last First MI
9. Billing phone #: (______)______________
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE
WITH DISABILITIES WITHOUT DISCRIMINATION
www.wcb.ny.gov
C-4.0 (10-15) Page 1 of 4
2. Carrier Code #: W
12. Patient's Account #:
6. Billing group or practice name:
Chiropractor
11. You are a (check one):
Podiatrist
Physician
Yes
No
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
Other
(specify):
3. Did another health provider treat this injury/illness including hospitalizaton and/or surgery?
E. History
No
Yes
4. Have you previously treated this patient for a similar work-related injury/illness?
F. Exam Information
Date of injury/onset of illness:______/______/______
Patient's Name:
Last First MI
1. Date(s) of Examination:
Medical Records
If yes, when: ________________________
Balance Due
(Carrier Use Only)
Amount Paid
(Carrier Use Only)
Total Charge
Use WCB Codes
$
Dates of Service
From
MM DD YY
To
MM DD YY
Place
of
Service
Leave
Blank
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).
(specify)
Weakness
Swelling
Stiffness
Pain
Other
2. Patient's subjective complaints: Check all that apply and identify specific affected body part(s).
Other
Fracture
Dislocation
Dermatitis
Crush Injury
Contusion/Hematoma
Burn
Bite
Avulsion
Amputation
Abrasion
(specify)
Vision Loss
Sprain/Strain
Spinal Cord Injury
Repetitive Strain Injury
Puncture Wound
Psychological
Poisoning/Toxic Effects
Infectious Disease
Hernia
Hearing Loss
Needle Stick
Laceration
3. Type/nature of injury: Check all that apply and identify specific affected body part(s).
Inhalation Exposure
Torn Ligament,Tendon or Muscle
Numbness/Tingling
If yes, give details:
www.wcb.ny.gov
C-4.0 (10-15) Page 2 of 4
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:
4. Physical examination: Check all relevant objective findings and identify specific affected body part(s).
H. Plan of Care
1. What is your proposed treatment?
2. Medication(s):(a) list medications prescribed: _____________________________________________________________________________
5. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________
6. Describe any treatment(s) rendered at this visit: ___________________________________________________________________________
3. Is the patient's history of the injury/illness consistent with your objective findings?
G. Doctor's Opinion
N/A (no findings at this time)
No
Yes
No
Yes
No
Yes
2. Are the patient's complaints consistent with his/her history of the injury/illness?
1. In your opinion, was the incident that the patient described the competent medical cause of this injury/illness?
4. What is the percentage (0-100%) of temporary impairment? _________%
(b) list over-the-counter medications advised:__________________________________________________________________
Medication restrictions:
None
May affect patient's ability to return to work, make patient drowsy, or other issue. Explain below:
7. Describe prognosis for recovery: _______________________________________________________________________________________
5. Describe findings and relevant diagnostic test results:______________________________________________________________________
________________________________________________________________________________________________________________
Yes
No
Other findings:___________________________________________________________________________________________________
Abnormal/Restricted ROM
Sensation
None at present
Pain/Tenderness
Wasting/Muscle Atrophy
Scar
Hematoma/Lump/Swelling
Laceration/Sutures
Joint Effusion
Crepitation
Burns
Bruising
Deformity
Palpable Muscle Spasm
Edema
Neuromuscular Findings:
Active ROM
Passive ROM
Gait
Strength (Weakness)
Reflexes
www.wcb.ny.gov
C-4.0 (10-15) Page 3 of 4
Date of injury/onset of illness:______/______/______
Patient's Name:
Last First MI
MRI (Specify):
X-rays (Specify):
CT Scan
Labs (Specify):
Other (Specify):
Internist/Family Physician
Chiropractor
Physical Therapist
Occupational Therapist
Specialist in
Other (Specify):
No
Yes
No
Yes
The patient can return to work without limitations on _______/_______/_______
The patient can return to work with the following limitations (check all that apply) on _______/_______/_______
Kneeling
Standing
Sitting
Lifting
Bending/twisting
Operating heavy equipment
Use of upper extremities
Personal protective equipment
Climbing stairs/ladders
Use of public transportation
Environmental conditions
Operation of motor vehicles
Other
1-2 days
3-7 days
8-14 days
15+ days
Unknown at this time
with patient
1. Has the patient missed work because of the injury/illness?
2. Can the patient return to work? (check only one):
b.
The patient cannot return to work because (explain):
a.
c.
(explain):
Describe/quantify the limitations:
How long will these limitations apply?
N/A
3. With whom will you discuss the patient's return to work and/or limitations?
N/A
3. Does the patient need diagnostic tests or referrals?
If yes, check all that apply:
Tests:
Referrals:
4. Assistive devices prescribed for this patient:
I. Work Status
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.
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.
Name
Board Authorized Health Care Provider signature:
Signature
Specialty
If yes, date patient first missed work:______/______/______
Is the patient currently working?
No
Yes
If yes, did the patient return to:
usual work activities
limited work activities
Within a week
1-2 weeks
3-4 weeks
5-6 weeks
7-8 weeks
Return as needed
months
5. When is the patient's next follow-up appointment?
Date
/ /
Provider's name___________________________________________________ Specialty______________________________________
with patient's employer
Cane
Crutches
Orthotics
Walker
Wheelchair
Other (specify): _______________________________________________________________________________________________
EMG/NCS
www.wcb.ny.gov
C-4.0 (10-15) Page 4 of 4
Date of injury/onset of illness:______/______/______
Patient's Name:
Last First MI
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.
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.
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.
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.
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
IMPORTANT TO THE ATTENDING DOCTOR
-
AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY
6.
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.
7.
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.
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.
C-4.0 (10-15)
MEDICAL REPORTING
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.
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.
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.
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.
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 Statewide Fax Line: 877-533-0337
