It is anticipated that all versions of the C-4 medical billing forms (except the C-4.3) will be replaced by the required XML submission of the CMS-1500 form on or about July 1, 2021. Learn more about the CMS-1500 Initiative.
The health care provider must be authorized by the NYS Workers' Compensation Board. If you are not an authorized health care provider and would like to become one, complete and submit Health Providers Application for Authorization Under the Workers' Compensation Law MR/IME-1
A User ID and Password is required to submit this form. Complete the online application to register for Web Submission of Medical Forms.
- Please Note: User IDs and passwords may only be created for NYS licensed, Workers' Compensation Board (WCB) authorized Health Care Providers (HCP). The user ID and password are associated directly to the HCP's WCB Board authorization number. Use of the user ID and password are considered to be the legal equivalent of the HCP actually signing the form by hand.
- Incomplete forms can be saved locally then completed and submitted through the Board's website at a later time.
- Template files with standard information (doctor, patient, carrier) can be saved and used as a basis for web submission of future reports.
Medical narratives must be attached. Please read "Attachment Requirements".
Upon successful submission, the health care provider will be provided with a printable PDF version of the form to keep for their records and to be used to send required copies of EC-4NARR and all attachments to 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. DO NOT MAIL THIS FORM TO THE BOARD.
To report permanent impairment, submit form Doctor's Report of MMI/Permanent Impairment (C-4.3).