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How to fill out the Form C4 online
Filling out Form C4 online is an essential task for reporting ancillary medical services in New York's workers' compensation cases. This guide will walk you through the process step-by-step, ensuring you understand each component of the form and can complete it accurately.
Follow the steps to complete the Form C4 online efficiently.
- Click the ‘Get Form’ button to access the form and open it in your designated editor.
- Begin by entering the patient's information. Fill in their last name, first name, middle initial, social security number, mailing address, home phone number, date of birth, date of injury or onset of illness, WCB case number, carrier case number, and patient account number as applicable.
- Next, provide the doctor’s information. Enter the physician's last name, first name, middle initial, WCB rating code, WCB authorization number, tax ID information (check whether it's the federal tax ID or social security number), office address, billing group name, office phone number, billing phone number, provider's NPI number, and referring doctor’s name.
- Complete the billing information section. This includes the employer's insurance carrier, carrier code number, insurance carrier's address, and details regarding the diagnosis or nature of the disease or injury. Enter appropriate ICD9 codes, service dates from and to, place of service, procedures, services or supplies, and total charges.
- Indicate if services were provided by a WCB preferred provider organization (PPO) and fill out the appropriate signature section for the authorized health care provider, including their name, specialty, and date.
- Finally, review all entered information for accuracy. Once confirmed, you can save your changes, download a copy of the completed form, print it for records, or share it via email or other means as necessary.
Start completing your Form C4 online today to ensure timely processing of your reports.
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