Get Ny Md-3 2011-2026

The NY MD-3 form is a crucial document for any carrier or self-insured employer objecting to a doctor's request for medical authorization. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently online.

Follow the steps to successfully fill out the NY MD-3 form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the WCB case number in the designated field. This is the number previously assigned to your case by the Workers’ Compensation Board.
3. Input the carrier case number in the corresponding space. This number is specific to the insurer or self-insured employer involved in the case.
4. Fill in the carrier code, which identifies the insurance carrier or self-insured employer responsible for this request.
5. Complete the name field with the name of the person or entity filing the objection.
6. Indicate the date of the injury related to the medical authorization request.
7. Provide the social security number of the claimant in the specified section.
8. Enter the full address of the claimant, ensuring accuracy to facilitate communication.
9. List the name of the employer involved in the claim.
10. If applicable, include the name of the representative authorized to act on behalf of the insurance carrier.
11. Write the name of the medical provider requesting authorization as referenced on Form MD-1.
12. State the date when Form MD-1 was mailed.
13. Clearly articulate the basis for your objection to the request for medical authorization, providing sufficient detail.
14. Sign the form in ink using a blue ballpoint pen if possible. Include your telephone number for follow-up.
15. Complete the Affidavit or Affirmation of Service on the reverse side of the form, selecting the appropriate method of service (mail or personal).

Ensure you complete your NY MD-3 form online today for timely processing.