Nysca Workers' Compensation Complaint Form printable pdf download

Nysca Workers' Compensation Complaint Form

Workers’ Compensation

Complaint Form

Dear Doctor – The Association is aware that injured workers’ compensation patients’ and their treating

providers are encountering problems and issues with the roll out of the new medical treatment

guidelines and the associated variance processes. The NYSCA has a meeting scheduled with

Workers’ Compensation March 3 to address some of these issues but we need to gather the

information necessary to bring these issues to the Board’s attention. Please provide a synopsis of an

issue you have encountered below and submit with a copy of your original bill and the EOB provided

by the WC carrier by Fax or mail to the address and telephone exchange below ASAP. Your patient

will need to sign an authorization form (attached) which should maintained in the patient’s record.

Carrier’s Name:

Carrier’s Address:

Claims Examiner’s Name:

Examiner’s Phone #:

Extension:

Patient # or First Name/First Initial - Last Name:

W CB Case #:

Date Called Carrier:

Date Billed/Variance Submitted:

Carrier’s Response:

Nature of Complaint:

Doctor’s Name:

Doctor’s Address:

Doctor’s Phone #:

Doctor’s Fax:

Doctor’s email address:

Submit with copies of the: 1) Original bill; and

2) EOB received from carrier

Mail to:

or Fax to:

NYSCA, 777 Lishakill Road, Niskayuna, NY 12309

518-785-6352

Remember to have your patient sign the attached Authorization Form for your office records.

Nysca Workers' Compensation Complaint Form