Get Form C 4 3

Filling out the Form C 4 3 online is an essential process for providing an opinion on maximum medical improvement and/or permanent impairment in workers' compensation cases. This guide offers clear and concise instructions to help users navigate each section of the form effectively.

Follow the steps to complete the Form C 4 3 online accurately.

1. Press the ‘Get Form’ button to access the form and open it in your online editor.
2. Begin with Section A, which requests the patient’s information. Fill in the patient's name, date of birth, social security number, address, home phone number, date of injury or illness, and patient's account number if applicable.
3. Move to Section B to provide the doctor's information. Include your name, WCB authorization number, federal tax ID number, office address, billing group or practice name, and office and billing phone numbers.
4. In Section C, enter complete billing information. Document the employer's insurance carrier, carrier code, insurance carrier address, and diagnosis or nature of the disease or injury along with the relevant ICD10 codes.
5. For Section D, determine and indicate whether the patient has reached maximum medical improvement (MMI). If they have, provide the date; if not, describe the reasons and the proposed treatment plan.
6. Proceed to Section E to assess and document permanent impairment. Indicate if there is permanent impairment and list the body parts and conditions treated related to the date of injury.
7. If applicable, complete Attachment A for schedule loss of use or preparation of a narrative report for serious facial disfigurement, hearing, or vision loss.
8. Fill out Attachment B for non-schedule permanent partial impairment if relevant, detailing the impairment classification and functional capabilities of the patient.
9. After all sections are completed, review the form for accuracy and ensure all necessary information is provided. Users can then save their changes, download, print, or share the completed form.

Complete your Form C 4 3 online and ensure accurate reporting for timely processing.