New York > Workers Compensation
Impartial Specialists Report Of Medical Records Review MR-4 - New York
| Impartial Specialists Report Of Medical Records Review Form. This is a New York form and can be used in Workers Compensation . |
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STATE OF NEW YORK - WORKERS' COMPENSATION BOARD IMPARTIAL SPECIALIST'S REPORT OF MEDICAL RECORDS REVIEW THIS RECORD REVIEW WAS REQUESTED BY THE WORKERS' COMPENSATION BOARD. This form should only be used for procedures that require pre-authorization under the Medical Treatment Guidelines. WCB CASE NO. CARRIER CASE NO. (IF KNOWN) DATE OF INJURY INJURED PERSON'S SOCIAL SECURITY NUMBER ADDRESS (Include Apt. No.) MR-4 DATE OF REVIEW INJURED PERSON EMPLOYER INSURANCE CARRIER (First Name) (Middle Initial) (Last Name) Treatment/Procedure Requested:____________________________________________________________________________ Results of Records Review (continue on reverse or attach additional sheets, if necessary) I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's condition. ________________________________________________ Impartial Specialist's Name ____________________________ Date Impartial Specialist's Signature Impartial Specialist's Address MR-4 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com It is unlawful for any person who has obtained individually identifiable information from Workers' Compensation Board records to disclose such information to any person who is not otherwise lawfully entitled to obtain these records. Any person who knowingly and willfully obtains workers' compensation records which contain individually identifiable information under false pretenses or otherwise violates Workers' Compensation Law Section 110-a shall be guilty of a class A misdemeanor and shall be subject upon conviction, to a fine of not more than one thousand dollars. HIPAA Notice: In order to adjudicate a workers' compensation claim, WCL Sections 13(e) permits the Board to have a claimant and/or his/her medical records examined by a designated health care provider. Pursuant to 45 CFR 164.512(l), a health care provider who has been retained by the Board to evaluate a workplace injury is exempt from HIPAA's restrictions on disclosure of health information. WORKERS' COMPENSATION BOARD DISTRICT OFFICES www.wcb.state.ny.us ALBANY 12241 - 100 Broadway, Menands. (866) 750-5157 For all accidents in following counties: Albany, Clinton, Columbia, Dutchess, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Ulster, Warren, Washington. BINGHAMTON 13901 - State Office Building, 44 Hawley Street. (866) 802-3604 For all accidents in following counties: Broome, Chemung, Chenango, Cortland, Delaware, Otsego, Schuyler, Sullivan, Tioga, Tompkins. BUFFALO 14203 - 295 Main Street, Suite 400. (866) 211-0645 For all accidents in following counties: Cattaraugus, Chautauqua, Erie, Niagara. ROCHESTER 14614 - 130 Main Street West. (866) 211-0644 For all accidents in following counties: Allegany, Genesee, Livingston, Monroe, Ontario, Orleans, Seneca, Steuben, Wayne, Wyoming, Yates. SYRACUSE 13203 - 935 James Street. (866) 802-3730 For all accidents in following counties: Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence. DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill district offices) - PO Box 5205, Binghamton, NY 13902-5205. NYC (800) 877-1373 Hemp. (866) 805-3630 Haup. (866) 681-5354 Peek. (866) 746-0552 For all accidents in following counties: Bronx, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Westchester. Statewide Fax Line: 877-533-0337 Address for Email Filing: wcbclaimsfiling@wcb.state.ny.us THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION MR-4 Reverse (1-11) American LegalNet, Inc. www.FormsWorkFlow.com
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