
Last updated: 7/16/2018
Attending Doctors Request For Optional Prior Approval And Carriers-Employers Response {MG-1}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
IMPORTANT: PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING HOW TO FIND INSURER/SELF-INSURER CONTACTS MG-1, ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL AND INSURER'S/EMPLOYER'S RESPONSE This form requires the name and fax number or email address of the insurer's designated contact listed on the Workers' Compensation Board's website. Insurer/Self-Insurer's designated contact information is available online at: wcb.ny.gov/medical-treatment-guideline-optional-prior-approval MG-1.0 (4-18) COVER SHEET(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines.) Patient's Name:The undersigned requests optional prior approval under the WCB Medical Treatment Guidelines as indicated below: Guideline Reference:(Attach if not already submitted.) A copy was sent to the Workers' Compensation Board (see the Board's email address and fax number on the reverse). I certify that I am making the above request for authorization. This request was made to the insurer/self-insurer using the following means of same-day transmission (A or B): INSURER'S / EMPLOYER'S RESPONSE (Response is due within 8 business days of receipt of this request or medical care is deemed approved (12 NYCRR 324.4(c)). The provider's request is: I certify that copies of this form were sent to the Treating Medical Provider requesting optional prior approval, the Workers' Compensation Board (see email address and fax number on the reverse). INSURER / EMPLOYER IS APPROVING THIS REQUEST FOR OPTIONAL PRIOR APPROVAL AFTER AN INITIAL DENIAL ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL AND INSURER'S/EMPLOYER'S RESPONSE FOR ADDITIONAL APPROVAL REQUESTS IN THIS CASE, ATTACH FORM MG-1.1 Answer all questions where information is known. MG-1MG-1.0 (4-18) C.D.E.F. DATE REQUEST SUBMITTED: Treatment/Procedure Requested: IF DENIED, STATE THE BASIS FOR THE DENIAL IN THE SPACE PROVIDED BELOW. SEE IMPORTANT INFORMATION FOR INSURER ON REVERSE. I certify that the provider's request for optional prior approval given above, which was initially denied on, is now granted. Granted Granted without Prejudice (see item 7 on reverse) Denied Individual Provider's WCB Authorization No.:-B.A.First MI Last Employer's Name & Address: Insurer's Name & Address: Social Security No.: Attending Doctor's Name & Address: Fax No.: Telephone No.: Patient's Address:Note: This form is used only if the employer/carrier participates in the Optional Prior Approval program. You can obtain participation status from the WCB Website. MEDICAL PROVIDER'S REQUEST FOR REVIEW BY MEDICAL ARBITRATOR OF DENIAL I hereby request review by a medical arbitrator designated by the Chair of the insurer's decision to deny optional prior approval of the above request. I understand that resolution by the medical arbitrator is binding and is not appealable under Workers' Compensation Law 24723. (Request is due within 14 calendar days of the date of denial.) Supporting medical report(s) datedis/are attached or available in the WCB case file. Provider's Signature: Date: Date: Title: By: (print name) By (print name): Title: Signature: Date: Provider's Signature: WCB Case #: Date of Injury/Illness: Claim Administrator Claim (Carrier Case) #: Name of the Medical Professional who Reviewed the Denial: Comments: Date of Service of Supporting Medical in WCB Case File: - NPI No.: Date: Signature: Designated contact information not available. A.Insurer's designated fax # or email address as provided on the Board's website: B.If the request was also submitted to another fax # or email address provided by the insurer, provide here:Provider must enter in A the designated fax or email address this request was sent to. Insurer/self-insurer's designated contact information is available online at: wcb.ny.gov/medical-treatment-guideline-optional-prior-approval. Check "Designated contact information not available", if appropriate. If the request was sent to a different (contact information is not available on Board's website) or additional fax or email address provided by the insurer, complete B. MG-1.0 4-18IMPORTANT TO TREATING MEDICAL PROVIDERMG-1.0 (4-18) Reverse1.This form is used for a workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit case as follows: Torequest optional confirmation from the insurer, self-insured employer, employer or Special Fund that the procedure or test is based ona correct application of the Medical Treatment Guidelines.2.This form must be signed by the treating medical provider and must contain her/his authorization number and code letters. Out-of-Statemedical providers must enter their NPI number. If the patient is hospitalized, it may be signed by a licensed doctor to whom thetreatment of the case has been assigned as a member of the attending staff of the hospital. The signature can be the original or astamp or an electronic signature as long as the medical provider has the intent to sign the completed form. The provider must reviewand approve each completed form. Also, someone else cannot sign the medical provider's name.3.Please ask the patient for his/her WCB case number, if available, and the claim administrator claim (carrier case) number and showthese numbers on this form.4.Provider must enter in A the designated fax or email address this request was sent to. Insurer/self-insurer's designated contactinformation is available online at: wcb.ny.gov/medical-treatment-guideline-optional-prior-approval . Check "Designated contactinformation not available", if appropriate. If the request was sent to a different (contact information is not available on Board's website)or additional fax or email address provided by the insurer, complete B. Failure to submit the request to the designated contactidentified on the Board's website may result in your request being denied. A copy should also be sent to the Board on the sameday using one of the prescribed methods of same day transmission.5.If authorization or denial is not forthcoming within 8 business days after the insurer has received the request, the test or treatment isdeemed approved and the Board will issue a Notice of Resolution stating the request is approved.6.If the insurer has checked "GRANTED WITHOUT PREJUDICE" on the front of this form, the liability for this claim has not yet beendetermined. This authorization is made pending final determination by the Board. Pursuant to 12 NYCRR 247 324.4(d) this authorizationis limited to the question of medical necessity only and is not an admission that the condition for which the services are required iscompensable. This authorization does not represent an acceptance of this claim by the insurer, self-insured employer, employer orSpecial Fund or guarantee payment for the services authorized. When a decision is rendered regarding liability, you will receive aNotice of Decision by mail. The insurer, self-insured employer, employer or Special Fund will only provide payment for these services ifthe claim is established and the insurer, self-insured employer, employer or Special Fund is found to be responsible for the claim. 7.Treating Medical Providers, which includes any physician, podiatrist, chiropractor or psychologist who is providing treatment and careto an injured worker pursuant to the Workers' Compensation Law, must treat injuries pursuant to the relevant Medical TreatmentGuidelines. The Medical Treatment Guidelines are posted on the Board's website. For additional information, please call (800)781-2362.8.The Medical Treatment Guidelines are the standard of care for injured workers. Additional information about the Medical TreatmentGuidelines, including e-learning training, is available on the Board's website.9.HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL 247 13-a(4)(a) and 12 NYCRR 247 325-1.3 require healthcare providers to regularly file medical reports of treatment with the Board and the insurer or employer. Pursuant to 45 CFR 247164.512these legally required medical reports ar
Related forms
-
Application For A Fee By Claimants Attorney Or Representative
New York/Workers Compensation/ -
Application For Acceptance Of Insurance Form
New York/Workers Compensation/ -
Application For Approval Of Non-Schedule Adjustment
New York/Workers Compensation/ -
Attending Psychologists Report
New York/Workers Compensation/ -
Carriers Report On Rehabilitation To Chair Workers Compensation Board
New York/Workers Compensation/ -
Claim For Compensation And Notice Of Commencement Of Third Party Action
New York/Workers Compensation/ -
Claim For Compensation In Death Case
New York/Workers Compensation/ -
Claimants Authorization To Disclose Workers Compensation Records
New York/Workers Compensation/ -
Notice And Proof Of Claim For Disability Benefits By Unemployed Claimant
New York/Workers Compensation/ -
Notice Of Disability Benefits Payment
New York/Workers Compensation/ -
Notice Of Election To Provide WC Benefits To Participants In A Sheltered Workshop
New York/Workers Compensation/ -
Notice To Liable Political Subdivision Of Volunteer Firefighters Injury Or Death
New York/Workers Compensation/ -
Notice To Liable Political Subdivision Or Unaffiliated Ambulance Service
New York/Workers Compensation/ -
Statement Of Unresolved Issues-Special Part For Expedited Hearings
New York/Workers Compensation/ -
Stipulation
New York/Workers Compensation/ -
Tables Of Statutory Employee Contributions Disability Benefits Law
New York/Workers Compensation/ -
Volunteer Firefighters Claim For Benefits
New York/Workers Compensation/ -
Carriers Request For Reimbursement Of Compensation Payments Under Section 14(6) (Blue Paper)
New York/Workers Compensation/ -
Claim For Volunteer Ambulance Workers Benefits In A Death Case
New York/Workers Compensation/ -
Claim For Volunteer Firefighters Benefits In A Death Case
New York/Workers Compensation/ -
Electronic Attachment
New York/Workers Compensation/ -
Proof Of Burial And Funeral Expenses By Undertaker
New York/Workers Compensation/ -
Proof Of Death By Physician Last In Attendance On Deceased
New York/Workers Compensation/ -
ADR Program Final Disposition Of Claim
New York/Workers Compensation/ -
Employees Statement Of Exempt Status
New York/Workers Compensation/ -
Employers Statement For Purpose Of Terminating Status As Covered Employer
New York/Workers Compensation/ -
Report Of Work-Related Injury Or Occupational Disease
New York/Workers Compensation/ -
Record Of Percentage Hearing Loss
New York/Workers Compensation/ -
Notice Of Termination Of Employers Participation In Self-Insured Association Union Or Trustees Plan
New York/Workers Compensation/ -
Section 110-a Affirmation-Affidavit
New York/Workers Compensation/ -
Affidavit For Death Benefits
New York/Workers Compensation/ -
Attending Doctors Request For Medical Authorization Determination
New York/Workers Compensation/ -
Carriers Or Self Insured Employers Objection To Attending Doctors Request For Medical Authorization Determination
New York/Workers Compensation/ -
Claimants Notice Of Independent Medical Examination
New York/Workers Compensation/ -
Employers Application To Have Association Union Or Trustee Plan Accepted As Employers Plan
New York/Workers Compensation/ -
Employers Report Of Injured Employees Change In Employment Status Resulting From Injury
New York/Workers Compensation/ -
Medical Proof Of Change Re Application For Reopening Claim
New York/Workers Compensation/ -
Volunteer Ambulance Workers Claim For Benefits
New York/Workers Compensation/ -
Carriers Request For Reimbursement Of Medical Expenses Under Section 15-8 (Pink Paper)
New York/Workers Compensation/ -
Notice Of Election To Bring Partners Members Or Self Employed Persons Under Coverage Of NYS WC Law
New York/Workers Compensation/ -
Notice Of Right To Select Workers Compensation Board Authorized Health Care Provider
New York/Workers Compensation/ -
Claimants Authorization To Disclose Workers Compensation Records (Autorizacion Del Reclamante - Spanish)
New York/Workers Compensation/ -
Attending Ophthalmologists Report
New York/Workers Compensation/ -
Notice Of Right To Reimbursement Of Compensation Payments
New York/Workers Compensation/ -
Disability Benefits Law Employer Identification Information
New York/Workers Compensation/ -
Health Insurers Request For Reimbursement
New York/Workers Compensation/ -
Health Providers Application For Authorization Under Workers Compensation Law
New York/Workers Compensation/ -
Notice To Chair Of Withdrawal Of Request For Arbitration
New York/Workers Compensation/ -
Claimants Authorization To Disclose Health Information (Pursuant To HIPAA)
New York/Workers Compensation/ -
Notice Of Election Of Corporation To Exclude Sole Shareholder Officer Or Executive Officers Shareholders From WC Coverage
New York/Workers Compensation/ -
Notice Of Election Of Municipal Corporation Or Other Polictical Subdivision To Bring Executive Officers Under WC Coverage
New York/Workers Compensation/ -
Notice Of Election Of Not For Profit Corp Or Unincorporated Assoc To Execlude Unsalaried Executive Officer From WC Coverage
New York/Workers Compensation/ -
Notice Of Retainer And Appearance On Behalf Of Employer
New York/Workers Compensation/ -
Revocation Of Election Of Corporation To Exclude Sole Shareholder Or Executive Officers From WC Coverage
New York/Workers Compensation/ -
Revocation Of Election Of Municipal Corporation Or Other Political Subdivision To Bring Executive Officers Under WC Coverage
New York/Workers Compensation/ -
Revocation Of Election Of Not For Profit Corp Or Unincorporated Assoc To Exclude Unsalaried Executive Officer From WC Coverage
New York/Workers Compensation/ -
Supplement To Certificate Of Insurance
New York/Workers Compensation/ -
Biannual Recertification To Entitlement To Benefits
New York/Workers Compensation/ -
Fraud Complaint
New York/Workers Compensation/ -
Affidavit Of Exemption - Proof Of WC Coverage For 1-2-3-4 Family Owner-Occupied Residence
New York/Workers Compensation/ -
Section 32 Settlement Agreement Claimant Release
New York/Workers Compensation/ -
Cover Sheet-List Of Itemized Medical Bills In Controverted World Trade Center Case
New York/Workers Compensation/ -
Registration Of Participation In WTC Rescue Recovery Clean Up Ops
New York/Workers Compensation/ -
Licensed Representatives Disclosure Of Conflict Of Interest To Client
New York/Workers Compensation/ -
Assigment To Chair WCB Of Cause Of Action Against Health Care Provider
New York/Workers Compensation/ -
Claim For Reimbursement Of Excess Benefits Paid Under Welfare Pension Or Benefit Plan
New York/Workers Compensation/ -
Notice Of Satisfaction Of WC Lien From Third Party Recovery
New York/Workers Compensation/ -
Notice Of Election Of Corporation To Exclude Shareholder Officers From Disability Coverage
New York/Workers Compensation/ -
Volunteers Notification Of Exec Officer Fire-Ambulance Company-Significant Risk Of HIV
New York/Workers Compensation/ -
Modification Of Previous Report (ADR Program)
New York/Workers Compensation/ -
Employee Claim
New York/Workers Compensation/ -
Limited Release Of Health Information (HIPAA)
New York/Workers Compensation/ -
Continuation To Carrier-Employer Billing Portion Of Forms C-4 C-4.2 C-4.3 C-5 PS-4 Or OT-PT-4
New York/Workers Compensation/ -
Doctors Progress Report
New York/Workers Compensation/ -
Reclamacion Del Empleado
New York/Workers Compensation/ -
Self Insurers Representatives Bond
New York/Workers Compensation/ -
Pre Hearing Conference Statement
New York/Workers Compensation/ -
Request For Judicial Order - Access To Case Files
New York/Workers Compensation/ -
Claimants Record Of Job Search Efforts Contacts
New York/Workers Compensation/ -
Consent To NYS Workers Compensation Board Jurisdiction For Non-New York Licensed Carriers (3C Coverage)
New York/Workers Compensation/ -
Agreed Upon Findings And Awards For Proposed Conciliation Decision (Represented Claimants Only)
New York/Workers Compensation/ -
Attending Doctors Request For Approval Of Variance And Carriers Response
New York/Workers Compensation/ -
Attending Doctors Request For Optional Prior Approval And Carriers-Employers Response
New York/Workers Compensation/ -
Continuation To Form MG-1 Attending Doctors Request For Optional Prior Approval
New York/Workers Compensation/ -
Continuation To Form MG-2 Attending Doctors Request For Approval Of Variance
New York/Workers Compensation/ -
Impartial Specialists Report Of Medical Records Review
New York/Workers Compensation/ -
Loss Of Wage Earning Capacity Vocational Data Form
New York/Workers Compensation/ -
Notice That Claimant Must Arrange For Diagnostic Tests And Examinations Through Network Provider
New York/Workers Compensation/ -
Initial Application To Take License Rep Exam To Appear On Behalf Of Claimants Or To Represent Carriers-Self-Insurers
New York/Workers Compensation/ -
Renewal Application For License To Appear On Behalf Of Claimant
New York/Workers Compensation/ -
Attorney-Representatives Certification Of Form C-3 Or Notice Of Controversy
New York/Workers Compensation/ -
Employers First Report Of Work-Related Injury Or Illness
New York/Workers Compensation/ -
Independent Examiners Report Of Request For Information Or Response To Request Regarding Ind Med Exam
New York/Workers Compensation/ -
Attorney-Licensed Representative Request To Withdraw From Representation
New York/Workers Compensation/ -
Paid Family Leave Supplement To Certificate Of Insurance
New York/Workers Compensation/ -
Employer Whistleblower Form
New York/Workers Compensation/ -
Attachment For Report Of Ind Med Exam Non Scheduled Perm Partial Disability
New York/Workers Compensation/ -
Attachment For Report Of Independent Med Exam Scheduled Loss Of Use
New York/Workers Compensation/ -
Application For Reconsideration Full Board Review
New York/Workers Compensation/ -
Rebuttal Of Application For Reconsideration Full Board Review
New York/Workers Compensation/ -
Section 32 Electronic Signature
New York/Workers Compensation/ -
Attending Doctors Request For Authorization And Insurers Response
New York/Workers Compensation/ -
Notice Of Treatment Issue(s)-Disputed Bill Issue(s)
New York/Workers Compensation/ -
Employers Statement Of Wage Earnings (Preceding Date Of Injury-Illness)
New York/7 Workers Compensation/ -
Claimants Record Of Independent Job Search Efforts
New York/7 Workers Compensation/ -
Application For Plan Of Employer - Disability And-Or Family Leave
New York/7 Workers Compensation/ -
Claimants Statement Regarding No Fault Or Personal Injury
New York/7 Workers Compensation/ -
Application Agreement Plan Of Association - Disability And-Or Family Leave
New York/7 Workers Compensation/ -
Physicians Application For Designation As Impartial Specialist
New York/7 Workers Compensation/ -
Physicians Application For Renewal Of Designation As Impartial Specialist
New York/7 Workers Compensation/ -
Report Of Impartial Specialist Examination Or Record Review
New York/7 Workers Compensation/ -
Application For Voluntary Binding Review
New York/7 Workers Compensation/ -
Voluntary Binding Review Parameters Agreement Section 32 WCL
New York/7 Workers Compensation/ -
World Trade Center September 11th Victim Compensation Fund Authorization
New York/7 Workers Compensation/ -
World Trade Center Volunteer HIPAA Authorization
New York/7 Workers Compensation/ -
Application For License To Represent Insurers And Or Self-Insurers
New York/Workers Compensation/ -
Notice And Proof Of Claim For Disability Benefits
New York/Workers Compensation/ -
Independent Examiners Report of Independent Medical Examination
New York/Workers Compensation/ -
Settlement Agreement - Section 32 WCL Indemnity Only Settlement Agreement
New York/Workers Compensation/ -
Statement Of Registration Section 13n-WCL IME Entity
New York/Workers Compensation/ -
Occupational Therapists Report Or Physical Therapists Report
New York/Workers Compensation/ -
Doctors Initial Report
New York/Workers Compensation/ -
Application For Reopening Of Claim More Than Seven Years After Accident
New York/Workers Compensation/ -
Waiver Agreement - Section 32 WCL
New York/Workers Compensation/ -
Employers Application Voluntary For Employees Benefits Not Required (No Contrib)
New York/Workers Compensation/ -
Employers Application Voluntary For Employees Benefits Not Required (Employee Contrib)
New York/Workers Compensation/ -
Direct Deposit Authorization Form
New York/7 Workers Compensation/ -
Notice Of Carriers Refusal To Pay Medical Bill
New York/7 Workers Compensation/ -
Notice Of Election To Voluntarily Exclude Spouse From Coverage
New York/Workers Compensation/ -
Ancillary Medical Report
New York/Workers Compensation/ -
Extreme Hardship Redetermination Request
New York/7 Workers Compensation/ -
Practitioners Report Of Functional Capacity Evaluation
New York/Workers Compensation/ -
Discharge Or Discrimination Complaint
New York/Workers Compensation/ -
World Trade Center Volunteers Claim For Compensation
New York/Workers Compensation/ -
Application For Board Review
New York/Workers Compensation/ -
Rebuttal Of Application For Board Review
New York/Workers Compensation/ -
Notice Of Retainer And Appearance Or Notice Of Substitution And Appearance
New York/Workers Compensation/ -
Claimants Record Of Medical And Travel Expenses And Request For Reimbursement
New York/7 Workers Compensation/ -
Notice That You May Be Responsible For Medical Costs
New York/Workers Compensation/ -
New York City Earned Sick and Safe Time
New York/7 Workers Compensation/ -
New Hire Reporting (Form IT-2104)
New York/7 Workers Compensation/ -
Carriers Request Benefit Increase Reimbursement Under VF-VAW Benefit Laws
New York/7 Workers Compensation/ -
Sexual Harassment Policy
New York/7 Workers Compensation/ -
Sexual Harassment Prevention Poster
New York/7 Workers Compensation/ -
Unemployment – Record of Employment
New York/7 Workers Compensation/ -
Carriers Or Self-Insured Employers Affirmation
New York/7 Workers Compensation/ -
Occupational Injury-Illness Statement Of Rights
New York/7 Workers Compensation/ -
Insurers Request For Reimbursement Of Medical Payments WCL Section 15(8)
New York/7 Workers Compensation/ -
Insurers Request For Reconsideration Of Reduction Under WCL § 14(6) Or 15(8)
New York/7 Workers Compensation/ -
Insurers Notification Of Initial Request For Reimbursement 14(6) Or 15(8)
New York/7 Workers Compensation/ -
Providers Request For Judgment Of Award
New York/Workers Compensation/ -
Request For Further Action By Insurer-Employer
New York/Workers Compensation/ -
Request For Assistance By Injured Worker
New York/Workers Compensation/ -
Request For Further Action By Legal Counsel
New York/Workers Compensation/ -
Doctors Report Of MMI-Permanent Impairment
New York/Workers Compensation/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!