C-4 Auth - Workers' Compensation Board Page 2

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STATEMENT OF MEDICAL NECESSITY

Pursuant to 12 NYCRR 325-1.4(a)(1), it is the attending physician's burden to set forth the medical necessity of the special services

required. Failure to do so may delay the authorization process.

Date of service of supporting medical in WCB Case File:

(Attach if not already submitted.)

I certify that I am making the above request for authorization. This request was made to the insurance carrier/self-insurer: (Complete A or B)

A. By fax on (date)

to (person contacted)

B. By telephone on (date)

to (person contacted)

and e-mailed/faxed/mailed on (date)

A copy of this form was sent to the Board on the date below.

Date:

Provider's Signature:

SELF-INSURED EMPLOYER / CARRIER RESPONSE TO AUTHORIZATION REQUEST

Response Time and Notification Required:

The self-insured employer/carrier must respond to the authorization request orally and in writing via e-mail, fax or regular mail with confirmation of

delivery within 30 days. The 30 day time period for response begins to run from the completion date of this form if e-mailed or faxed, or the

completion date plus five days if sent via regular mail. The written response shall be on a copy of this form completed by the physician seeking

authorization and shall clearly state whether the authorization has been granted, granted without prejudice, or denied. Authorization can only be

granted without prejudice when the compensation case is controverted or the body part has not yet been established. Authorization without

prejudice shall not be construed as an admission that the condition for which these services are required is compensable or the employer/carrier

is liable. The employer/carrier shall not be responsible for the payment of such services until the question of compensability and liability is

resolved. Written response must be sent to the health care provider, claimant, claimant's legal counsel, if any, the Workers' Compensation Board

and any other parties of interest.

Denial of the Request for Authorization of a Special Service: A denial of authorization of a special service must be based upon and

accompanied by a conflicting second opinion rendered by a physician authorized to conduct IMEs, or record review, or qualified medical

professional, or a physician authorized to treat workers' compensation claimants. (If authorization is denied in a controverted case, the conflicting

second opinion must address medical necessity only.) When denying authorization for a special service, the employer/carrier must also file with

the Board within 5 days of such denial Form C-8.1 Part A (Notice of Treatment Issue(s)/Disputed Bill Issue(s)). Failure to file timely the conflicting

second opinion and Form C-8.1 Part A will render the denial defective. If denial of an authorization is based upon claimant's failure to attend an

IME examination scheduled within the 30 day authorization period, contemporaneous supporting evidence of claimant's failure must be attached.

Failure to Timely Respond to Form C-4 AUTH: The special service(s) for which authorization has been requested will be deemed authorized

by Order of the Chair if the self-insured employer/carrier fails to respond within the time specified above. An Order of the Chair is not subject to an

appeal under Section 23 of the Workers' Compensation Law.

REASON FOR DENIAL(S), IF ANY. (ATTACH OR REFERENCE CONFLICTING SECOND MEDICAL OPINION AS EXPLAINED ABOVE.)

Date of service of supporting medical in WCB case file:

I certify that the self-insured employer/carrier telephoned the office of the health care provider listed above within the response time-frame

indicated above and advised that the self-insured employer/carrier had either granted or denied approval for the special services for which

authorization was sought, as indicated above, on the date below:

and

I certify that copies of this form were e-mailed, faxed, or mailed to the health care provider, the claimant, the claimant's legal counsel, if any, the

Workers' Compensation Board and all parties of interest on the date below:

By: (print name)

Title:

Date:

Signature:

C-4AUTH (12-14) Page 2 of 2