Form C-4.2 - Doctor'S Progress Report - 2015

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C-4.2
Doctor's Progress Report
Use this form to report continuing services. (To report the first time you treated the patient, use Form C-4. To
report permanent impairment, use Form C-4.3.)
Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or
licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment
of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.
wcb.ny.gov.
Date(s) of Examination: ______________________________________________________________________________________________
WCB Case Number (if known):
Carrier Case Number (if known):
A. Patient's Information
-
-
2. Date of injury/illness: _____/_____/_____ 3. Soc. Sec. #:
1. Name:
Last
First
MI
4. Address
:
(if changed from previous report)
Number and Street
City
State
Zip Code
5. Patient's Account #:
B. Doctor's Information
1. Your name:
2. WCB Authorization #:
Last
First
MI
3. WCB Rating Code:
The Tax ID # is the (check one ):
4. Federal Tax ID #:
SSN
EIN
5. Office address:
Number and Street
City
State
Zip Code
6. Billing Group or Practice Name:
7. Billing address:
Number and Street
State
Zip Code
City
10. Treating Provider's NPI #:
8. Office phone #: (______)_____________
9. Billing phone #: (______)______________
C. Billing Information
1. Employer's insurance carrier:
2. Carrier Code #: W
3. Insurance carrier's address:
Number and Street
City
State
Zip Code
4. Diagnosis or nature of disease or injury:
Enter ICD10 Code:
ICD10 Descriptor:
(1)
(2)
(3)
(4)
Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column below by line.
Use WCB Codes
Dates of Service
Procedures, Services or Supplies
Place of
Leave
Days/
Diagnosis Code
$ Charges
COB
Zip code where service
From
To
Blank
Units
Service
CPT/HCPCS
MODIFIER
was rendered
MM
DD
YY
MM
DD
YY
Total Charge
Amount Paid
Balance Due
Check here if services were provided by a WCB preferred provider organization (PPO).
(Carrier Use Only)
(Carrier Use Only)
$
$
$
D. Examination and Treatment
1. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________
C-4.2 (10-15) Page 1 of 2

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