List of Available Forms for Health Care Providers
Please Note: It is anticipated that all versions of the C-4 medical billing forms (except the C-4.3) and the OT/PT-4 will be replaced by the required XML submission of the CMS-1500 form on July 1, 2021. Learn more about the CMS-1500 Initiative.
The health care provider must be authorized by the NYS Workers' Compensation Board.
A user ID and password is required to submit these online forms. This is the same user ID and password used to access the Board’s Medical Portal. When a form listed below is filed with the Board, it is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
Request User ID
To sumbit a form, log in to the Medical Portal and select the link for Web Submission of Medical Forms.
Medical Portal Login
After successful submission, a confirmation of receipt by the Board and printable PDF version of the form will appear in your web browser. You will need to keep a copy of the PDF and provide copies to other interested parties.
| Form Number | Form Title | Who Can Submit | Comments |
|---|---|---|---|
| C-4 | Doctor's Initial Report |
|
Use this form to report the first time you treated the patient. |
| C-4.2 | Doctor's Progress Report |
|
Use this form to report continuing services. |
| C-4.3 | Doctor's Report of MMI/Permanent Impairment |
|
Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment. |
|
EC-4 AMR Web Submission Process Overview |
Ancillary Medical Report | Health Care Provider authorized by the NYS Workers' Compensation Board | This form may be used to file reports for ancillary medical services such as x-ray, pathology or diagnostic services by other than the attending provider in workers' compensation, volunteer firefighter's or volunteer ambulance workers' benefit cases. |
|
EC-4NARR
Web Submission Process Overview |
Doctor's Narrative Report |
|
This form may be used to report the first time you treated the patient or to report continuing services. (To report permanent impairment,use Form C-4.3.) Use this form only if attaching a detailed narrative report. See Attachment Requirements for topics that must be addressed in the narrative attachment. |
|
OT/PT-4 |
Occupational Therapist's/ Physical Therapist's Report |
|
48 hour initial report, within 48 hours of first treatment. 15 day report, within 17 days of first treatment. 45 day progress report, at 45 day intervals while continuing treatment. |
If the form you are looking for is not available for online submission, you may print the PAPER version of the form from our list of common forms.
