C-4 Auth - Workers' Compensation Board

Download a blank fillable C-4 Auth - Workers' Compensation Board in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete C-4 Auth - Workers' Compensation Board with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION
C-4
AND CARRIER'S RESPONSE
AUTH
State of New York - Workers' Compensation Board
Answer all questions fully on this report
WCB Case Number:
Carrier Case Number:
Date of Injury:
A
.
Patient's Name: ......................................................................................................................................Social Security No.: ..................................................
First
MI
Last
Address: ....................................................................................................................................................................................................................................
Number and Street
City
State
Zip Code
Employer's Name: .....................................................................................................................................................................................................................
Address: ....................................................................................................................................................................................................................................
Number and Street
City
State
Zip Code
Insurance Carrier's Name: ........................................................................................................................................................................................................
Address: ....................................................................................................................................................................................................................................
Number and Street
City
State
Zip Code
B.
Attending Doctor's Name: .........................................................................................................................................................................................................
Address: ...................................................................................................................................................................................................................................
Number and Street
City
State
Zip Code
Individual Provider's WCB Authorization No.: ............................................ Telephone No.: ....................................... Fax No.: ............................................
C.
AUTHORIZATION REQUEST
The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to the Medical Treatment Guidelines. Do
NOT use this form for injuries/illnesses involving the Mid and Low Back, Neck, Knee, Shoulder and Non-Acute Pain, except for the treatment/procedures listed below under Medical
Treatment Guideline Procedures Requiring Pre-Authorization. Please use the appropriate Medical Treatment Guideline form if any other procedure/test is being requested.
Authorization Requested:
Carrier Response: if any service
is denied, explain on reverse.
Diagnostic Tests:
Granted
Granted w/o Prejudice
Denied
Radiology Services (X-Rays, CT Scans, MRI) indicate body part:
Granted
Granted w/o Prejudice
Denied
Other
Therapy (including Post Operative):
times per week for
weeks
Granted
Granted w/o Prejudice
Denied
Physical Therapy:
weeks
Granted
Granted w/o Prejudice
Denied
OccupationalTherapy:
times per week for
Granted
Granted w/o Prejudice
Denied
Other
Surgery:
Granted
Granted w/o Prejudice
Denied
Type of Surgery (Describe, include use of hardware/surgical implants)
Granted
Granted w/o Prejudice
Denied
Treatment:
Granted
Granted w/o Prejudice
Denied
Other
Medical Treatment Guidelines Procedures Requiring Pre-Authorization
(Complete Guideline Reference for each item checked, if necessary. In first box, indicate
injury and/or condition: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, P = Non-Acute Pain. In remaining boxes, indicate corresponding section of WCB
Medical Treatment Guidelines.)
B
-
E
4
a
1. Lumbar Fusions
............................................................................. 1.
Granted
Granted w/o Prejudice
Denied
E
-
2. Artificial Disk Replacement
Granted
Granted w/o Prejudice
Denied
........................................................... 2.
B
E
7
a
i
3. Vertebroplasty
-
................................................................................ 3.
Granted
Granted w/o Prejudice
Denied
B
E
7
a
i
-
4. Kyphoplasty
.................................................................................... 4.
Granted
Granted w/o Prejudice
Denied
E
a
-
5. Electrical Bone Growth Stimulators
............................................... 5.
Granted
Granted w/o Prejudice
Denied
K
D
1
f
-
6. Osteochondral Autograft
................................................................ 6.
Granted
Granted w/o Prejudice
Denied
K
D
1
f
-
7. Autologous Chondrocyte Implantation
.............................................7.
Granted
Granted w/o Prejudice
Denied
K
D
-
8. Meniscal Allograft Transplantation
.................................................8.
Granted
Granted w/o Prejudice
Denied
K
F
2
9. Knee Arthroplasty (total or partial knee joint replacement)
-
Granted
Granted w/o Prejudice
Denied
............9.
P
G
1
-
10. Spinal Cord Stimulators
................................................................. 10.
Granted
Granted w/o Prejudice
Denied
P
-
G
2
11. Intrathecal Drug Delivery (pain pumps)
Granted
Granted w/o Prejudice
Denied
.........................................11.
-
12. Second or Subsequent Procedure
Granted
Granted w/o Prejudice
Denied
................................................12.
C-4AUTH (12-14) Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3