State Of New York Workers' Compensation Board - Attending Doctor'S Request For Medical Authorization Determination
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1
2STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
ATTENDING DOCTOR'S REQUEST FOR MEDICAL AUTHORIZATION DETERMINATION
INSTRUCTIONS:
This form may be used by an attending doctor whenever a carrier or self-insured employer has not responded within 30 days
to the doctor's request for authorization for special services costing more than $500. File this form with the Workers'
Compensation Board district office where the case is pending (see addresses on reverse), and simultaneously with the
claimant's workers' compensation insurance carrier. Complete all items. Incomplete forms will not be processed. All of
the following conditions must be met before you file this form:
1.
You have contacted the carrier or self-insured employer by telephone and requested authorization for special services
costing more than $500.
2.
You have sent the carrier or employer and filed a copy with the Board Form C-4 with item 4 checked "Yes" requesting
authorization for special services costing more than $500.
3.
At least thirty (30) days have elapsed since your initial telephone contact with no response from the carrier or
self-insured employer. Please note that any response from the carrier, such as a denial of your request, precludes the
Board from issuing a determination authorizing such special services.
4.
Please complete items 1. through 22. below, making sure that the doctor's signature and the signature of the person
certifying the mailing date are original.
6.
INJURED PERSON'S
3. DATE OF
4.
1. WCB CASE NO.
2. CARRIER CASE NO. (IF KNOWN)
5. ADDRESS WHERE INJURY OCCURRED (CITY, TOWN OR VILLAGE)
INJURY
& TIME
SOCIAL SECURITY NUMBER
9. TELEPHONE NO.
(First Name)
(Middle Initial)
(Last Name)
8. ADDRESS (Include Apt. No.)
7.
INJURED
PERSON
11. PATIENT'S DATE
OF BIRTH
10.
EMPLOYER*
12.
INSURANCE
CARRIER
13.
SUPER-
VISING
PHYSICIAN
(if any)
14. *If treatment was under the VFBL or VAWBL show as "Employer" the liable political subdivision and check one:
VFBL
VAWBL
15. SPECIAL SERVICES REQUESTED
16. VERBAL REQUEST FOR AUTHORIZATION FROM CARRIER:
a. NAME OF EMPLOYEE CONTACTED____________________________________________________________________________
b. DATE OF TELEPHONE CALL REQUESTING AUTHORIZATION___________________ c. TELEPHONE NO.__________________
17. DATE FORM C-4 WAS SENT REQUESTING AUTHORIZATION
18. DOCTOR'S NAME AND ADDRESS
19. DOCTOR'S TELEPHONE NUMBER
20. DOCTOR'S WCB AUTHORIZATION NUMBER
21. I SUBSCRIBE AND AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THESE STATEMENTS ARE TRUE AND CORRECT.
DOCTOR'S SIGNATURE_________________________________________________ DATE ___________________________
22. I hereby certify that a copy of this form was mailed to the carrier/self-insured employer named above on___________.
Signature______________________________________________________ (black or blue ink only)
MD-1 (12-03)
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