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Attending Doctors Request For Approval Of Variance And Carriers Response MG-2 - New York
| Attending Doctors Request For Approval Of Variance And Carriers Response Form. This is a New York form and can be used in Workers Compensation . |
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ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF VARIANCE AND CARRIER'S RESPONSE State of New York - Workers' Compensation Board MG-2 For additional variance requests in this case, attach Form MG-2.1. Answer all questions where information is known. WCB Case Number: Carrier Case Number: Date of Injury: Social Security No.: First MI Last A. Patient's Name: Patient's Address: Employer's Name & Address: Insurance Carrier's Name & Address: B. Attending Doctor's Name & Address: Individual Provider's WCB Authorization No.: Telephone No.: Fax No.: C. The undersigned requests approval to VARY from the WCB Medical Treatment Guidelines as indicated below: Guideline Reference: (In first box, indicate body part: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, C = Carpal Tunnel. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If the treatment requested is not addressed by the Guidelines, in the remaining boxes use NONE.) Approval Requested for: (one request type per form) STATEMENT OF MEDICAL NECESSITY - See item 4 on instruction page. Your explanation must provide the following information: - the basis for your opinion that the medical care you propose is appropriate for the claimant and is medically necessary at this time; and - an explanation why alternatives set forth in the Medical Treatment Guidelines are not appropriate or sufficient. If applicable, your explanation must also provide: - the symptoms, signs, or lack of improvement that compel you to seek the proposed treatment, or - a description of the functional outcomes that, as of the date of the variance request, have continued to demonstrate objective improvement from that treatment and are reasonably expected to further improve with additional treatment. - the specific duration or frequency of treatment for which a variance is requested. You have the option to submit citations or copies of relevant literature published in recognized, peer-reviewed medical journals as part of the basis in support of this variance request. Date of service of supporting medical in WCB case file, if not attached: Date(s) of previously denied variance request for substantially similar treatment, if applicable: I certify that I am making the above request for approval of a variance and my affirmative statements are true and correct. I certify that I have read and applied the Medical Treatment Guidelines to the treatment and care in this case and that I am requesting this variance before rendering any medical care that varies from the did / did not contact the carrier by telephone to discuss Guidelines. I certify that the claimant understands and agrees to undergo the proposed medical care. I this variance request before making the request. I contacted the carrier by telephone on (date) and spoke to (person spoke to or was not able to speak to anyone) A copy of this form was sent to the carrier/employer/self-insured employer/Special Fund by (fax number or email address required) A copy was sent to the Workers' Compensation Board, and copies were provided to the claimant's legal counsel, if any, to the claimant if not represented, and to any other parties of interest within two (2) business days of the date below. I am not equipped to send or receive forms by fax or email. This form was mailed to the parties indicated above on In addition, I certify that I do not have a substantially similar request pending and that this request contains additional supporting medical evidence if it is substantially similar to a prior denied request. Provider's Signature: MG-2.0 (2-13) Page 1 of 2 Date: THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com Patient Name: WCB Case Number: Date of Injury: D. CARRIER'S / EMPLOYER'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION (IME) OR MEDICAL RECORDS REVIEW The self-insurer/carrier hereby gives notice that it will have the claimant examined by an Independent Medical Examiner or the claimant's medical records reviewed by a Records Reviewer and submit Form IME-4 within 30 calendar days of the variance request. By: (print name) Signature: Title: Date: E. CARRIER'S / EMPLOYER'S RESPONSE TO VARIANCE REQUEST Carrier's response to the variance request is indicated in the checkboxes on the right. Carrier denial, when appropriate, should be reviewed by a health professional. (Attach written report of medical professional.) If request is approved or denied, sign and date the form in Section E. CARRIER'S / EMPLOYER'S RESPONSE If service is denied or granted in part, explain in space provided. Granted Granted in Part Denied Burden of Proof Not Met Substantially Similar Request Pending or Denied Without Prejudice Name of the Medical Professional who reviewed the denial, if applicable: I certify that copies of this form were sent to the Treating Medical Provider requesting the variance, the Workers' Compensation Board, the claimant's legal counsel, if any, and any other parties of interest, with the written report of the medical professional in the office of the carrier/employer/selfinsured employer/Special Fund attached, within two (2) business days of the date below. (Please complete if request is denied.) If the issue cannot be resolved informally, I opt for the decision to be made by the Medical Arbitrator designated by the Chair or at a WCB Hearing. I understand that if either party, the carrier or the claimant, opts in writing for resolution at a WCB hearing; the decision will be made at a WCB hearing. I understand that if neither party opts for resolution at a hearing, the variance issue will be decided by a medical arbitrator and the resolution is binding and not appealable under WCL ยง 23. By: (print name) Signature: Title: Date: F. DENIAL INFORMALLY DISCUSSED AND RESOLVED BETWEEN PROVIDER AND CARRIER I certify that the provider's variance request initially denied above is now granted or partially granted. By: (print name) Carrier's Signature: Title: Date: G. CLAIMANT'S / CLAIMANT REPRESENTATIVE'S REQUEST FOR REVIEW OF SELF-INSURED EMPLOYER'S / CARRIER'S DENIAL NOTE to Claimant's / Claimant Licensed Representative's: The claimant should only sign this section after the request is fully or partially denied. This section should not be completed at the time of initial request. YOU MUST COMPLETE THIS SECTION IF YOU WANT THE BOARD TO REVIEW THE CARRIER'S DENIAL OF THE PROVIDER'S VARIANCE RE
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