Ame) STATE OF NEW YORK WORKERS' COMPENSATION BOARD (Middle Initial) DATE OF INJURY & TIME (Last Name) SERVICES PROVIDED UNDER WCB PREFERRED PROVIDER ORGANIZATION (PPO) PROGRAM? YES NO PLEASE TYPE ALL INFORMATION - COMPLETE ALL ITEMS ADDRESS WHERE INJURY OCCURRED (CITY, TOWN OR VILLAGE) INJURED PERSON'S SOCIAL SECURITY NUMBER ADDRESS (Include Apt. No.) TELEPHONE NO. PATIENT'S DATE OF BIRTH EMPLOYER* INSURANCE CARRIER TELEPHONE NO. REFERRING PHYSICIAN *If treatment was under the VFB.
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How to fill out the NY PS-4 online
The New York PS-4 form is essential for reporting information in workers' compensation cases. This guide will walk you through each section of the form to ensure accurate and complete submissions.
Follow the steps to fill out the NY PS-4 form effectively.
- Press the ‘Get Form’ button to access the NY PS-4 form and open it in the document editor.
- Begin by entering the injured person's full name: first name, middle initial, and last name. Ensure all names are typed clearly.
- Fill in the injured person's social security number and date of birth. This information is crucial for identification.
- Provide the address where the injury occurred, including the city, town, or village. Also, enter the complete address of the injured person.
- Enter the telephone number of the injured person for any necessary follow-up.
- Complete the employer and insurance carrier sections, ensuring to include contact information if applicable.
- In section 1, describe the incident or occupational history that resulted in symptoms. Provide as much detail as possible.
- Address whether the patient has any pre-existing psychological conditions in section 2. Detail any relevant history.
- For section 3, select the appropriate referral type — evaluation only, treatment only, or both — and complete the corresponding items.
- Document the date of the first visit and whether further visits are scheduled. Indicate if the patient has resumed work.
- In sections 8 and 9, enter the diagnosis, ICD10 code, and provide the nature of the injury, along with relevant dates of service.
- Provide billing information including total charges, amount paid, and any balances due.
- Complete the form by ensuring the treating psychologist's signature, name, address, and phone number are included.
- Once you finish entering all the required information, save your changes, and choose to download, print, or share the filled document as needed.
Complete the NY PS-4 form online to ensure swift processing of your report.
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