L SPECIALIST IMPORTANT INSTRUCTIONS TO PHYSICIANS You must apply for renewal at least 60 days prior to the end of your current 5 year term. Complete both sides of this application. All entries are to be typewritten or printed clearly. Return the completed form to the Workers' Compensation Board, Medical Director's Office, 100 Broadway-Menands, Albany, NY, 12241. If you have any questions regarding the completion of this form, you may contact us at the above noted address or call 1-800-781-2362.
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How to fill out the NY IS-1R online
The NY IS-1R is a physician's application for renewal of designation as an impartial specialist in New York. This guide provides clear, step-by-step instructions to help users navigate and complete the form accurately and efficiently.
Follow the steps to complete the NY IS-1R form online.
- Click the ‘Get Form’ button to access the NY IS-1R form in your preferred editor.
- Begin filling out the form by entering your date of birth in the appropriate field.
- Input your full name, including first name, middle initial, and last name.
- Provide your home address, including the county, and ensure that your home phone number is included.
- Enter your New York Medical License Number, along with the date the license was granted and the expiration date.
- List your office locations within New York State, ensuring to include primary and other office addresses with corresponding phone numbers.
- Fill in your tax identification number in the specified field.
- Indicate whether you are employed by any health provider organization or related entities and provide details if applicable.
- Respond to questions regarding your work with insurance carriers, employers, or unions and include any necessary narratives.
- Report if you are authorized to render care under the Workers' Compensation Law or conduct independent medical examinations, including providing relevant years and authorization numbers.
- Answer questions regarding your clinical practice in the previous years and submit additional details as required.
- Affirm whether your professional license has faced any suspensions, limitations, or disciplinary actions and provide necessary details.
- Indicate if you can accommodate claimants who speak languages other than English and explain how.
- State your availability for testimony by stating the days of the week you can provide it.
- Finally, review all your entries for accuracy, sign the form, and date it.
- After completing the form, you can save your changes, download, print, or share the form as needed.
Complete your application by filling out the NY IS-1R form online today.
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