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Subject Number 046-301R Mandatory Use of New And Revised Medical Report Forms on April 1, 2009

Board Bulletins and Subject Numbers

Revises Subject No. 046-301 issued March 13, 2009. See additional information in red below.

March 23, 2009

This release is to remind all doctors that they must use the new C-4 family of forms for any and all treatment provided on and after April 1, 2009.

The Board will not enforce payment for any examinations, services and/or treatments provided that are not reported using the correct new C-4 form for services provided on and after April 1, 2009. In addition, the Board will investigate why the doctor is not using the correct new form and, if warranted, issue an administrative warning or commence temporary suspension or revocation proceedings.

PLEASE NOTE: While the new C-4 family of forms must be used to report services and/or treatments provided effective April 1, 2009, the doctor has the option of including a HCFA-1500 or CMS-1500 form for billing purposes only along with the prescribed Board medical report.

Doctors and or facilities contracting with an XML Submission Vendor, (Clearinghouse) for the submission of Form EC-4NARR have the option of submitting to the carrier, the CMS 1500 along with the required narrative and the other required fields contained in the submission.

Please note the following exceptions:


On September 17, 2008, the Chair announced the implementation of a revised set of core forms (Subject Number 046-250), including changes to the Attending Doctor's Report (Form C-4) and the addition of new medical forms. Form C-4 has been renamed the Doctor's Initial Report and is only completed the first time a doctor treats a claimant for a particular workers' compensation claim. This initial report must be filed within 48 hours of first rendering treatment. For subsequent visits the Board created Form C-4.2 (Doctor's Progress Report), a shorter version of Form C-4. Form C-4.2 must be filed at intervals of 45 days during continuing treatment, unless change of condition necessitates additional reporting. When a patient with a permanent impairment reaches maximum medical improvement, doctors will now complete a third form, Form C-4.3 (Doctor's Report of MMI/Permanent Impairment). All of the new C-4 family of forms can be submitted electronically through the Board's website, or by mail in paper form.

Subsequent to the release of these forms, the Board released an additional form, C-4AMR (Ancillary Medical Report), for providers of ancillary services to report their services in a simplified format. Also, an electronic narrative version of Forms C-4 and C-4.2 (Form EC-4NARR), was developed, which contains significantly fewer questions than C-4 and C-4.2. Doctors submitting Form EC-4NARR must include a narrative attachment with the form that will provide all the additional information which otherwise would be on the other forms. Form EC-4NARR will only be accepted by the Board through electronic submission.

Doctors were informed that they should begin using the new forms as soon as possible but by no later than January 1, 2009. Subject No. 046-273 extended this deadline to April 1, 2009 to allow doctors additional time to familiarize themselves with the changes and to implement them into their office software and/or business practices.

All of the new and revised forms are available in the Health Care Providers Forms section of the Board's website.

Thank you for your cooperation.

Zachary S. Weiss