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  • Please allow 15 minutes to complete the application.
  • The application must be completed in one sitting. You cannot save an application that is in progress and return at a later time to complete it. You will lose the information that you entered and will need to start over.
  • The information that appears in the electronic application form corresponds to the provider type you selected when you signed up to access the Medical Portal.
  • When you attach your application, a copy will be emailed to you at the email address provided on your application.
  • Once your application has been reviewed by the Board, you will receive an email notification with the Board’s decision.

Checklist of information or attachments* needed to complete the application:

  • All providers must take the Workers’ Compensation Board’s training for their provider type
  • All providers must attach a Curriculum Vitae/Resume – information to include in this document: Name, NYS license number, graduate and post graduate education, additional academic training/certifications, Board Certification, Specialty/Sub specialty, professional memberships and experience
  • Attach Certificate of Board Certification (if applicable)
  • Physician Assistants must attach a Supervising Physician Affirmation form, signed by the Board authorized supervising physician.
  • Attach Disciplinary action documents (if applicable)
  • Individual NPI
  • Provider’s email address – used for Board correspondence (Use of Health Care Provider Emails)
  • Mailing address – used for Board correspondence
  • Practice name and address(es) – displayed on the Board’s Provider Search page
  • Contact address – used to schedule independent medical examinations

*Attachments must be in PDF format. The filename must only contain letters and numbers, no special characters including parenthesis, dashes or underscores. The size per attachment cannot exceed 5 MB. Use the paperclip icon located in the purple bar at the top right of your screen in the application to attach a document.

Due to scheduled system maintenance, the Initial Authorization Application will not be available between 11 pm Fridays and 7:30 am Saturdays.

Complete the initial authorization application