New York > Workers Compensation
Carriers Or Self Insured Employers Objection To Attending Doctors Request For Medical Authorization Determination MD-3 - New York
| Carriers Or Self Insured Employers Objection To Attending Doctors Request For Medical Authorization Determination 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 DOWNSTATE CENTRALIZED MAILING (for New York City, Hempstead, Hauppauge & Peekskill Districts) PO Box 5205 Binghamton, NY 13902-5205 NYC (800)877-1373 / Hemp. (866)805-3630 / Haup. (866)681-5354 / Peek. (866)746-0552 100 Broadway State Office Building 295 Main Street Menands Suite 400 44 Hawley Street 935 James St. 130 Main Street W. ALBANY 12241 BINGHAMTON 13901 BUFFALO 14203 ROCHESTER 14614 SYRACUSE 13203 (866) 750-5157 (866) 211-0645 (866) 802-3604 (866) 802-3730 (866) 211-0644 CARRIER'S/SELF -INSURED EMPLOYER'S OBJECTION TO ATTENDING DOCTOR'S REQUEST FOR MEDICAL AUTHORIZATION DETERMINATION WCB Case Number Carrier Case Number Carrier Code Date of Injury Social Security Number Name Address Claimant Employer Carrier Representative, If Any Medical Provider Requesting Authorization on Form MD -1 Insurance Carrier/Self-Insured Employer making objection: _______________________________ Date Form MD -1 Mailed:__________________________________________________________ Basis for Objection: _______________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Signature:_____________________________ Tel. No.: ________________ Date:____________ (Ink only - Use blue ballpoint pen if possible.) Signer's Name and Title (Please Print):________________________________________________ TO THE SIGNER: The original should be sent directly to the appropriate Board address, as shown at the top of this form. A copy of this objection must be sent to all parties in interest and the medical provider who requested authorization. Complete the Affidavit or Affirmation of Service on the reverse side of this form. MD -3 (1-11) www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com AFFIRMATION OF SERVICE STATE OF NEW YORK, COUNTY OF _________________________ ss: I, the undersigned, am an attorney admitted to practice in the courts of New York State, and on __________________, I served a date true copy of this form and attachments in the following manner (check one): Service by Mail By mailing the same in a sealed envelope, with postage prepaid thereon, in a post -office or official depository of the U.S. Postal Service within the State of New York, addressed to the last known address of the addressee(s) as indicated below: Personal Service By delivering the same personally to the persons and at the addresses indicated below: I affirm that the foregoing statements are true under penalties of perjury. _____________________________________________________ Signature Dated: _________________ _____________________________________________________ Signer's Name (Please Print) AFFIDAVIT OF SERVICE STATE OF NEW YORK, COUNTY OF __________________________ ss: _______________________________________________ being sworn says: I am over 18 years of age and on __________________, I served a true copy of this form and attachments in the following manner (check one): date Service by Mail By mailing the same in a sealed envelope, with postage prepaid thereon, in a post -office or official depository of the U.S. Postal Service within the State of New York, addressed to the last known address of the addressee(s) as indicated below: Personal Service By delivering the same personally to the persons and at the addresses indicated below: Sworn to before me on _____________________. ______________________________________________________________ Date Signature ________________________________________ _______________________________________________________________ Signer's Name (Please Print Notary Public MD -3 (1-11) Reverse www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com
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