Follow the steps to successfully complete the NY OT/PT-4 form online.

1. Click ‘Get Form’ button to access the document and open it in the editor.
2. Start by entering the personal details of the injured person, including their first name, middle initial, last name, and social security number. Ensure that all information is typed clearly to prevent errors.
3. Input the date and time of the injury, as well as the address where the incident occurred. This includes the city, town, or village.
4. Complete the section regarding the services provided under the WCB preferred provider organization program. Choose 'yes' or 'no' and provide details if applicable.
5. Fill in the employer information and the insurance carrier details, including telephone numbers, if known.
6. Document the referral details. Specify whether the referral was for evaluation, treatment, or both by checking the appropriate box.
7. Provide a detailed diagnosis as conveyed by the referring physician or podiatrist, filling in any history of pre-existing conditions as required.
8. List the dates of service for the treatment provided. Include the diagnosis code and explain any unusual circumstances.
9. After completing all necessary fields, review the form for accuracy before saving changes.
10. Finally, users can save the document, print it for submission, or share it as needed before finalizing the report.

Complete your NY OT/PT-4 form online today to ensure prompt processing of your workers' compensation claims.