Form Mg-2 Nys -Attending Doctor'S Request For Approval Of Variance And Carrier'S Response Page 2
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1
2
3
4Patient Name:
WCB Case Number:
Date of Injury:
D.
CARRIER'S / EMPLOYER'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION (IME) OR MEDICAL RECORDS REVIEW
The self-insurer/carrier hereby gives notice that it will have the claimant examined by an Independent Medical Examiner or the claimant's medical
records reviewed by a Records Reviewer and submit Form IME-4 within 30 calendar days of the variance request.
By: (print name)
Title:
Signature:
Date:
E.
CARRIER'S / EMPLOYER'S RESPONSE TO VARIANCE REQUEST
Carrier's response to the variance request is indicated in the checkboxes on the right. Carrier
CARRIER'S / EMPLOYER'S RESPONSE
denial, when appropriate, should be reviewed by a health professional. (Attach written report of
If service is denied or granted in part, explain in space provided.
medical professional.) If request is approved or denied, sign and date the form in Section E.
Granted
Without
Prejudice
Granted in Part
Denied
Burden of Proof Not Met
Substantially Similar
Request Pending or Denied
Name of the Medical Professional who reviewed the denial, if applicable:
I certify that copies of this form were sent to the Treating Medical Provider requesting the variance, the Workers' Compensation Board, the claimant's
legal counsel, if any, and any other parties of interest, with the written report of the medical professional in the office of the carrier/employer/self-
insured employer/Special Fund attached,
within two (2) business days of the date below.
(Please complete if request is denied.) If the issue cannot be resolved informally, I opt for the decision to be made
by the Medical Arbitrator
designated by the Chair or
at a WCB Hearing. I understand that if either party, the carrier or the claimant, opts in writing for resolution at a WCB
hearing; the decision will be made at a WCB hearing. I understand that if neither party opts for resolution at a hearing, the variance issue will be
decided by a medical arbitrator and the resolution is binding and not appealable under WCL § 23.
By: (print name)
Title:
Signature:
Date:
F.
DENIAL INFORMALLY DISCUSSED AND RESOLVED BETWEEN PROVIDER AND CARRIER
I certify that the provider's variance request initially denied above is now granted or partially granted.
By: (print name)
Title:
Carrier's Signature:
Date:
G.
CLAIMANT'S / CLAIMANT REPRESENTATIVE'S REQUEST FOR REVIEW OF SELF-INSURED EMPLOYER'S / CARRIER'S DENIAL
NOTE to Claimant's / Claimant Licensed Representative's: The claimant should only sign this section after the request is fully or partially denied.
This section should not be completed at the time of initial request.
YOU MUST COMPLETE THIS SECTION IF YOU WANT THE BOARD TO REVIEW THE CARRIER'S DENIAL OF THE PROVIDER'S VARIANCE REQUEST.
I request that the Workers' Compensation Board review the carrier's denial of my doctor's request for approval to vary from the Medical
Treatment Guidelines. I opt for the decision to be made
by the Medical Arbitrator designated by the Chair or
at a WCB Hearing. I
understand that if either party, the carrier or the claimant, opts in writing for resolution at a WCB hearing; the decision will be made at a WCB
hearing. I understand that if neither party opts for resolution at a hearing, the variance issue will be decided by a medical arbitrator and the
resolution is binding and not appealable under WCL § 23.
Claimant's / Claimant Representative's Signature:
Date:
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR
BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL
STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205
Customer Service Toll-Free Number: 877-632-4996
MG-2.0 (12-14)
Page 2 of 2
FAX NUMBER: 877-533-0337
E-MAIL TO: wcbclaimsfiling@wcb.ny.gov
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