Form C-4auth - Attending Doctor'S Request For Authorization And Carrier'S Response

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C-4
ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION
AUTH
AND CARRIER'S RESPONSE
State of New York - Workers' Compensation Board
Answer all questions fully on this report
WCB Case Number:
Carrier Case Number:
Date of Injury:
Patient's Name: ............................................................................................................................................................................................................
First
MI
Last
Social Security Number: ...................................................................................................
Employer's Name: ........................................................................................................................................................................................................
Insurance Carrier's Name: ............................................................................................................................................................................................
Address: ........................................................................................................................................................................................................
Number and Street
City
State
Zip Code
Attending Doctor's Name: .............................................................................................................................................................................................
Provider's Authorization Number: .....................................................................................
Address: ........................................................................................................................................................................................................
Number and Street
City
State
Zip Code
Telephone Number: ..................................................................... Fax Number: ........................................................................................
AUTHORIZATION REQUEST
The undersigned requests written authorization for the following special service(s) costing over $1,000, which are not on the pre-authorized list.
Authorization Requested:
Carrier Response: If any service
is denied, explain on reverse.
Diagnostic Tests (indicate body part)
X-Rays ..................................................................................................................................
Granted
Denied
CT Scan ................................................................................................................................
Granted
Denied
MRI .......................................................................................................................................
Granted
Denied
EMG/NCV
UE ..............................................................................................(L, R or B)
Granted
Denied
LE ...............................................................................................(L, R or B)
Granted
Denied
Nerve Blocks .........................................................................................................................
Granted
Denied
Orthopedic Evaluation ...........................................................................................................
Granted
Denied
Neurological Evaluation ........................................................................................................
Granted
Denied
Other .....................................................................................................................................
Granted
Denied
Treatment
Physical Therapy ( ____ times per week for _____ weeks)
Granted
Denied
Occupational Therapy ( ____ times per week for _____ weeks)
Granted
Denied
Other ............................................................( ____ times per week for _____ weeks)
Granted
Denied
Surgery
Type of Surgery ....................................................................................................................
Granted
Denied
...............................................................................................................................................
Surgical Implants ..................................................................................................................
Granted
Denied
Post-OP Physical Therapy ( _____ times per week for _____ weeks)
Granted
Denied
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
C-4AUTH (9-08) Page 1 of 2

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