Form C-4auth - Attending Doctor'S Request For Authorization And Carrier'S Response Page 3

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IMPORTANT TO ATTENDING DOCTOR

REQUEST FOR WRITTEN AUTHORIZATION

AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY

This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case as follows:

To confirm a telephone request for written authorization for special service(s) costing over $1,000 in a non-emergency situation.

SPECIAL SERVICES - Services for which authorization must be requested are as follows:

Physicians - To engage the services of a specialist, consultant, or a surgeon, or to provide for X-ray examinations or physiotherapeutic

or other procedures, or other procedures, or to provide for special diagnostic laboratory tests costing more than $1,000.

Podiatrists - In treating the foot, to provide physiotherapeutic procedures, X-ray examinations, or special diagnostic laboratory tests

costing more than $1,000.

Chiropractors - In treating a condition as provided in Section 6551 of the Education Law, to engage the services of a specialist,

consultant, or a surgeon, or to provide for X-ray examinations or physiotherapeutic or other procedures, or to provide for special

diagnostic laboratory tests costing more than $1,000.

Occupational/Physical Therapists - In treating a condition as provided in Article 136 or 156 of the Education Law, in the Workers'

Compensation Law, and the Rules of the Chair relative to Occupational/Physical Therapy Practice to provide occupational/physical

therapy procedures costing more than $1,000.

When requesting authorization over the telephone, be sure to obtain the name of the person contacted since you must indicate this

information along with the date of contact and certify its validity on the form.

It is the attending physician's burden to set forth the medical necessity of the special services required. Be sure to provide this

information in the Statement of Medical Necessity section of this form.

This form must be signed by the attending doctor (original signature only) and must contain her/his authorization certificate number and

code letters. If the patient is hospitalized, it may be signed by a licensed doctor to whom the treatment of the case has been assigned as

a member of the attending staff of the hospital.

Please ask your patient for his/her WCB case number and the carrier's case number and show these numbers on this form. In addition,

ask your patient if he/she has retained a representative. If represented, ask for the name and address of the representative.

This request must be sent to the Workers' Compensation Board, the workers' compensation insurance carrier or self-insured employer,

and, if the patient is represented by an attorney or licensed representative, such legal representative. If your patient is not represented, a

copy must be sent to your patient.

If authorization or denial is not forthcoming within the 4 working days if the patient is hospitalized, or within the 30 calendar days if the

patient is not hospitalized, notify the nearest office of the Workers' Compensation Board.

HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care

providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these

legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.

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.

WORKERS' COMPENSATION BOARD DISTRICT OFFICES

Reports should be filed by sending directly to the appropriate WCB district office (DO) at the address below with a copy sent to the insurance carrier:

Albany DO - 100 Broadway-Menands, Albany NY 12241 866-750-5157 (for accidents in the following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton,

Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington)

Binghamton DO - State Office Building, 44 Hawley Street, Binghamton NY13901 866-802-3604 (for accidents in the following counties: Broome, Chemung, Chenango, Cortland,

Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins)

Buffalo DO - Statler Towers, 107 Delaware Avenue, Buffalo NY 14202 866-211-0645 (for accidents in the following counties: Cattaraugus, Chautauqua, Erie, Niagara)

Rochester DO - 130 Main Street West, Rochester NY 14614 866-211-0644 (for accidents in the following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans,

Seneca, Steuben, Wayne, Wyoming, Yates)

Syracuse DO - 935 James Street, Syracuse NY 13203 866-802-3730 (for accidents in the following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga,

Oswego,St. Lawrence)

Downstate Centralized Mailing - PO Box 5205, Binghamton NY, 13902-5205 for all DO's in NYC 800-877-1373; in Hempstead 866-805-3630; in Hauppauge 866-681-5354;

in Peekskill 866-746-0552 (for accidents in the following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester)

THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION

C-4 AUTH (9-08)