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

.......................................................................................................................................................................................................................................

I certify that I am making the above request for authorization. This request was made by telephone on (date) _________________ to (person

contacted) ____________________________ This form was also mailed to the self-insured employer/carrier and a copy was provided to the

Board on the date below.

Provider's Signature: .......................................................................................................................... Date: ..............................................................

SELF-INSURED EMPLOYER / CARRIER RESPONSE TO AUTHORIZATION REQUEST

Response Time and Notification Required:

If claimant is hospitalized: The self-insured employer/carrier must grant or deny each request for authorization of special service to

the doctor by telephone within 4 working days. This response must be confirmed in writing by completing this form and mailing it, within five

days of the examination of the patient, to the doctor, claimant's legal counsel if any, and the Workers' Compensation Board.

If claimant is not hospitalized: The self-insured employer/carrier must grant or deny each request for authorization of special service

to the doctor by telephone and confirm its response in writing by completing this form and mailing it, within thirty days, to the doctor,

claimant's legal counsel if any, and the Workers' Compensation Board.

Denial of the Request for Authorization of a Special Service: A denial of authorization of a special service to an established body part must

be based upon and accompanied by a conflicting second opinion rendered by a physician authorized to treat workers' compensation claimants.

If the compensation case is controverted, the conflicting second opinion must address medical necessity only and such authorization shall not be

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

for the payment of such services until the question of compensability is resolved. When denying authorization for a special service, the employer/

carrier must also file with the Board within 5 days of such denial Board Form C-8.1 Part A (Notice of Treatment Issue(s)/Disputed Bill Issue(s)).

Failure to file timely the conflicting second opinion and Board Form C-8.1 Part A will render the denial defective.

Failure to Timely Respond to 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 CONFLICTING SECOND MEDICAL OPINION AS EXPLAINED ABOVE.)

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 mailed to the health care provider listed above and to the Workers' Compensation Board on the date below:

By: .................................................................................................................................... Title: ..................................................................................

(Please print name)

Signature: ........................................................................................................................................ Date: ..................................................................

C-4AUTH (9-08) Page 2 of 2