and a list of records that were reviewed, to the Board within 20 days of the examination, or in the case of a review of records only, within 25 days of receipt of records, or by such date directed by the Board. CARRIER CASE NO. WCB CASE NO. Patient's Name: Patient's Address: First Name Middle Initial DATE OF INJURY Last Name DATE OF EXAMINATION Date of Birth: Telephone No.: Employer's Name & Address: Insurance Carrier's Name & Address: Results of Examination or Record Review: Attach Re.
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How to fill out the NY IS-4 online
Navigating forms can be challenging, particularly when accuracy is crucial. This guide provides a step-by-step approach to completing the NY IS-4 form, offering clear direction to ensure your submission is thorough and timely.
Follow the steps to successfully complete the NY IS-4 form.
- Click ‘Get Form’ button to obtain the form and open it in the designated editor.
- Begin by entering the carrier case number and WCB case number at the top of the form. Ensure the information is accurate to avoid processing delays.
- Fill in the patient's personal details. This includes the patient's first name, middle initial, last name, date of birth, address, and telephone number.
- Indicate the date of injury clearly, followed by the date of examination. Accurate dates will facilitate smoother case handling.
- Record the employer's name and address, ensuring that this matches the information documented in the case file.
- Provide the insurance carrier's name and address, as this information is vital for processing the report.
- Summarize the results of the examination or record review in the designated area. Ensure to attach any relevant reports that support your findings.
- Certify the report by entering your name and license number. This certification indicates that the report is a truthful representation of your professional opinion.
- Specify your availability for testimony by indicating the days of the week and times (AM or PM) that you can be reached.
- Sign the document and include the date of signing. This step concludes your report.
- Once completed, save changes to the document. You can opt to download, print, or share the form as needed.
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