Get Ny C-4.3 2018-2025

The NY C-4.3 form is essential for healthcare providers to report on a patient's maximum medical improvement and permanent impairment related to workers' compensation cases. This guide will provide a step-by-step method for filling out the form online accurately and efficiently.

Follow the steps to complete the NY C-4.3 form online.

1. Use the ‘Get Form’ button to access and open the NY C-4.3 form in the designated online editor.
2. Begin by filling in the date(s) of examination and the WCB case number if known in the designated fields. Dual check that the information is accurate.
3. In Section A, provide the patient's information including their name, date of birth, social security number, address, home phone number, date of injury, and patient account number. Ensure every field is filled in completely to prevent delays.
4. Proceed to Section B to fill in your information as the healthcare provider. This includes your name, WCB authorization number, and federal tax ID number, along with your office address and contact details.
5. In Section C, provide detailed billing information including the employer's insurance carrier, carrier code, diagnosis or nature of the disease or injury, and associated charges for services rendered.
6. Move on to Section D, where you will indicate if the patient has reached maximum medical improvement (MMI). If yes, provide the date; if no, describe the expected treatment plan.
7. In Section E, specify whether there is a permanent impairment. If applicable, list all body parts treated and complete any necessary attachments related to schedule loss of use or other impairments.
8. After filling out the sections thoroughly, review all provided information for accuracy, ensuring no fields are left incomplete.
9. Once all sections are complete, save your changes. You can then download, print, or share the form as necessary for submission to the Workers' Compensation Board, insurance carrier, and the patient's attorney or representative.

Complete your documents online efficiently and accurately today.