New York > Workers Compensation
Continuation To Carrier-Employer Billing Portion Of Forms C-4 C-4.2 C-4.3 C-5 PS-4 Or OT-PT-4 C-4.1 - New York
| Continuation To Carrier-Employer Billing Portion Of Forms C-4 C-4.2 C-4.3 C-5 PS-4 Or OT-PT-4 Form. This is a New York form and can be used in Workers Compensation . |
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CONTINUATION TO CARRIER/EMPLOYER BILLING PORTION OF FORMS C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4 Doctor's Name WCB Case Number Carrier Case Number Date of Accident or Injury Patient Patient's Social Security Number: A MM 7. Dates of Service From DD YY MM To DD YY B C D CPT/HCPCS (USE WCB CODE) MODIFIER E Diagnosis Code F $ Charges G Days or Units H COB I Zip Code Where Service was Rendered Place Leave of Blank Service Procedures, Services or Supplies 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. C-4.1 (9-08) THE INJURED WORKER SHOULD NOT PAY THIS BILL. NY-WCB American LegalNet, Inc. www.FormsWorkflow.com
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