New York > Workers Compensation
Continuation To Form MG-1 Attending Doctors Request For Optional Prior Approval MG-1.1 - New York
| Continuation To Form MG-1 Attending Doctors Request For Optional Prior Approval Form. This is a New York form and can be used in Workers Compensation . |
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CONTINUATION TO FORM MG-1, ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL Patient WCB Case Number Carrier Case Number MG-1.1 Date of Injury Doctor's Name Doctor's WCB Authorization Number Patient's Social Security Number INSTRUCTIONS TO ATTENDING DOCTOR: This form is not to be filed separately. Attach to completed Form MG-1 if requesting optional prior approval for additional treatment(s) or procedure(s) in the same case. A. The undersigned requests additional optional approval under the WCB Medical Treatment Guidelines as indicated below: 2. Treatment/Procedure Requested 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.) CARRIER'S/EMPLOYER'S RESPONSE (Carrier/employer must complete certification on reverse of this form) Date of Service of Supporting Medical in WCB Case File (attach if not in file): Comments: Granted Granted without Prejudice Denied 3. Treatment/Procedure Requested 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.) CARRIER'S/EMPLOYER'S RESPONSE (Carrier/employer must complete certification on reverse of this form) Date of Service of Supporting Medical in WCB Case File (attach if not in file): Comments: Granted Granted without Prejudice Denied 4. Treatment/Procedure Requested 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.) CARRIER'S/EMPLOYER'S RESPONSE (Carrier/employer must complete certification on reverse of this form) Date of Service of Supporting Medical in WCB Case File (attach if not in file): Comments: Granted Granted without Prejudice Denied 5. Treatment/Procedure Requested 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.) CARRIER'S/EMPLOYER'S RESPONSE (Carrier/employer must complete certification on reverse of this form) Date of Service of Supporting Medical in WCB Case File (attach if not in file): Comments: Granted Granted without Prejudice Denied I certify that I am making the above request for optional prior approval and my affirmative statements are true and correct. I did / did not contact the carrier by telephone to discuss this request before making it. I contacted the carrier by telephone on (date) and spoke to (person spoken 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 e-mail address required) A copy was sent to the Workers' Compensation Board, and copies were provided to the claimant's legal counsel, if any, and to any other parties of interest on the date below. Provider's Signature: MG-1.1 (2-13) Date: THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. NY-WCB American LegalNet, Inc. www.FormsWorkFlow.com B. CARRIER'S / EMPLOYER'S RESPONSE (Response is due in 8 business days from receipt of this request or medical care is deemed approved (12 NYCRR 324 (c)). IF ANY REQUESTS ARE DENIED, GIVE REASON(S) IN THE SPACE PROVIDED BELOW. Identify reasons according to Request No. 2-5 on the front of this form. Name of the medical professional who reviewed the denial(s): I certify that copies of this form were went to the Treating Medical Provider requesting optional prior approval, the Workers' Compensation Board (see mailing and email addresses and fax number on Form MG-1), the claimant's legal counsel, if any, and any other parties of interest, on the date below. By: (print name) Signature: Title: Date: C. MEDICAL PROVIDER'S REQUEST FOR BOARD REVIEW OF DENIAL I hereby request review by a medical arbitrator designated by the Chair of the carrier's decision to deny optional prior approval of the request(s) checked below. I understand that resolution by the medical arbitrator is binding and is not appealable under Workers' Compensation Law Section 23. (Request is due within 14 calendar days of the date of denial.) Supporting medical report(s) dated is/are attached or is/are available in the WCB case file. Request No. 2 Request No. 3 Request No. 4 Request No. 5 Provider's Signature: Date: D. CARRIER / EMPLOYER IS APPROVING ADDITIONAL REQUEST(S) FOR OPTIONAL PRIOR APPROVAL AFTER AN INITIAL DENIAL I certify that the provider's request for optional prior approval given above, which was initially denied on following request(s): Request No. 2 By: (print name) Signature: Request No. 3 Request No. 4 Request No. 5 Title: Date: , is now granted for the MG-1.1 (2-13) www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com
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