New York > Workers Compensation
Continuation To Form MG-2 Attending Doctors Request For Approval Of Variance MG-2.1 - New York
| Continuation To Form MG-2 Attending Doctors Request For Approval Of Variance Form. This is a New York form and can be used in Workers Compensation . |
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CONTINUATION TO FORM MG-2, ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF VARIANCE Patient WCB Case Number Carrier Case Number MG-2.1 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-2 if requesting approval for additional variance(s) in the same case. Supporting medical must be attached or identified for each request. A. The undersigned requests additional approval(s) to VARY from the WCB Medical Treatment Guidelines as indicated below: 2. 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.) Date(s) of previously denied variance request Date of service of supporting medical in WCB case file (attach if not in file): Approval Requested for: Medical Necessity: (for substantially similar treatment, if applicable): 3. 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.) Date(s) of previously denied variance request Date of service of supporting medical in WCB case file (attach if not in file): Approval Requested for: Medical Necessity: (for substantially similar treatment, if applicable): 4. 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.) Date(s) of previously denied variance request Date of service of supporting medical in WCB case file (attach if not in file): Approval Requested for: Medical Necessity: (for substantially similar treatment, if applicable): 5. 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.) Date(s) of previously denied variance request Date of service of supporting medical in WCB case file (attach if not in file): Approval Requested for: Medical Necessity: (for substantially similar treatment, if applicable): STATEMENT OF MEDICAL NECESSITY - See requirements on Form MG-2. 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. MG-2.1 (2-13) CONTINUED ON REVERSE NY-WCB American LegalNet, Inc. www.FormsWorkFlow.com Patient Name: WCB Case Number: Date of Injury: HEALTH PROVIDER'S CERTIFICATION 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 e-mail address required) A copy was sent (see address on instruction page) 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. 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: Date: B. CARRIER'S/EMPLOYER'S NOTICE OF INDEPENDENT MEDICAL EXAMINATION (IME) OR MEDICAL RECORDS REVIEW The carrier/employer hereby gives notice that it will have the claimant examined by an Independent Medical Examiner and submit Form IME-4 within 30 calendar Request No. 2 Request No. 3 Request No. 4 Request No. 5 days of the Variance Request, with respect to: By: (print name): Signature: Title: Date: C. CARRIER'S/EMPLOYER'S RESPONSE TO ADDITIONAL VARIANCE REQUEST(S) Carrier's response to the variance request is indicated in the checkboxes below. If any additional request(s) are denied, give reason(s) for denial or partial granted below. Identify reasons according to Request No. 2-5. (Attach written report of medical professional for each denial as explained on Form MG-2.) Request No. 2: Request No. 3: Request No. 4: Request No. 5: Granted Granted Granted Granted Granted in Part Without Prejudice Denied Denied Denied Denied Burden of Proof Not Met Burden of Proof Not Met Burden of Proof Not Met Burden of Proof Not Met Substantially Similar Request Pending or Denied Substantially Similar Request Pending or Denied Substantially Similar Request Pending or Denied Substantially Similar Request Pending or Denied Granted in Part Without
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