Please Note: All versions of the C-4 medical billing forms (except the C-4.3) and the OT/PT-4 were replaced by the required submission of the CMS-1500 form on July 1, 2022. 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).
To submit a form, log in to the Medical Portal and select the link for Web Submission of Medical Forms.
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-4.3||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.
If the form you are looking for is not available for Web Submission, you may print the paper version of the form from our list of common forms. For the CMS-1500, contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores; or contract with an XML Submission Partner to electronically submit the bill.