Get Ny Md-1 2011-2026
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How to fill out the NY MD-1 online
The NY MD-1 form is utilized by attending doctors to request authorization for special services costing more than $1,000 when a response has not been received from the insurance carrier or self-insured employer within 30 days. This guide provides step-by-step instructions to ensure users can complete the form accurately and efficiently online.
Follow the steps to fill out the NY MD-1 online:
- Click the ‘Get Form’ button to obtain the NY MD-1 document and access it for completion.
- Begin by entering the WCB Case Number at the top of the form.
- Next, fill in the Carrier Case Number if known, followed by the Date of Injury and the Time of Injury.
- Provide the address where the injury occurred, including city, town, or village.
- Enter the injured person's Social Security Number.
- Fill out the injured person's telephone number and their residential address, ensuring that you include the apartment number if applicable.
- Indicate the patient’s date of birth.
- Provide the employer’s name and if applicable, indicate if treatment is under the VFBL or VAWBL, checking the appropriate box.
- Specify the special services requested.
- Document the verbal request for authorization from the carrier, including the name of the employee contacted, date of the telephone call requesting authorization, and their telephone number.
- Record the date the Form C-4 was sent requesting authorization.
- Enter the doctor’s name and address, including their telephone number and WCB authorization number.
- In the signature section, the doctor must sign the form in ink, preferably using a blue ballpoint pen, and date their signature.
- Lastly, certify that a copy of the form was mailed to the carrier or self-insured employer, signing again in ink, and providing the mailing date.
- Once all information is completed, save changes, download, print, or share the filled form as needed.
Complete the NY MD-1 form online today to ensure timely processing of medical authorization requests.
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