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Doctors Progress Report C-4.2 - New York

Doctors Progress Report Form. This is a New York form and can be used in Workers Compensation .
 Fillable pdf Last Modified 9/18/2013
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Use this form to report continuing services. (To report the first time you treated the patient, use Form C-4. To report permanent impairment, use Form C-4.3.) Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.wcb.Q\JRY. Date(s) of Examination: ______________________________________________________________________________________________ WCB Case Number (if known): Carrier Case Number (if known): 2. Date of injury/illness: _____/_____/_____ 3. Soc. Sec. #: City State State of New York - Workers' Compensation Board Doctor's Progress Report C-4.2 A. Patient's Information 1. Name: Last First MI - Zip Code 4. Address (if changed from previous report): 5. Patient's Account #: Number and Street B. Doctor's Information 1. Your name: 3. WCB Rating Code: 5. Office address: 6. Billing Group or Practice Name: 7. Billing address: Number and Street City State Zip Code Last First MI 2. WCB Authorization #: The Tax ID # is the (check one): City State 4. Federal Tax ID #: Number and Street SSN Zip Code EIN 8. Office phone #: (______)_____________ 9. Billing phone #: (______)______________ 10. Treating Provider's NPI #: C. Billing Information 1. Employer's insurance carrier: 3. Insurance carrier's address: Number and Street 4. Diagnosis or nature of disease or injury: Enter ICD9 Code: ICD9 Descriptor: (1) (2) (3) (4) Relate ICD9 codes in (1), (2), (3), or (4) to Diagnosis Code column below by line. Dates of Service From MM To DD YY MM DD YY Place Leave of Service Blank 2. Carrier Code #: W City State Zip Code Use WCB Codes Procedures, Services or Supplies CPT/HCPCS MODIFIER Diagnosis Code $ Charges Days/ Units COB Zip code where service was rendered Check here if services were provided by a WCB preferred provider organization (PPO). Total Charge Amount Paid (Carrier Use Only) Balance Due (Carrier Use Only) D. Examination and Treatment $ $ $ 1. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________ _________________________________________________________________________________________________________________ THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE C-4.2 (1) Page 1 of 2 www.wcb.Q\JRY WITH DISABILITIES WITHOUT DISCRIMINATION American LegalNet, Inc. Patient's Name: Last First MI Date of injury/onset of illness:______/______/______ 2. List any changes revealed by your most recent examination in the following: area of injury, type/nature of injury, patient's subjective complaints or your objective findings: _____________________________________________________________________________________________ 3. List additional body parts affected by this injury, if any: ______________________________________________________________________ 4. Based on your most recent examination, list changes to the original treatment plan, prescription medications or assistive devices, if any: Yes No 5. Based on this examination, does the patient need diagnostic tests or referrals? Referrals: Tests: EMG/NCS CT Scan Chiropractor MRI (specify): Occupational Therapist Labs (specify): Physical Therapist X-rays (specify): Specialist in: Other (specify): Other (specify): 6. Describe treatment rendered today: 3-4 wks If yes, check all that apply: Internist/Family Physician Important: Form C-4 AUTH should be used to request any special medical service over $1000 or for those services requiring pre-authorization pursuant to the Medical Treatment Guidelines for the back, neck, knee and shoulder. 7. When is patient's next follow-up visit? Within a week 1-2 wks 5-6 wks 7-8 wks ____ months as needed E. Doctor's Opinion (based on this examination) 1. In your opinion, was the incident that the patient described the competent medical cause of this injury/illness? Yes No 2. Are the patient's complaints consistent with his/her history of the injury/illness? No Yes 3. Is the patient's history of the injury/illness consistent with your objective findings? Yes No N/A (no findings at this time) 4. What is the percentage (0-100%) of temporary impairment? ______________% 5. Describe findings and relevant diagnostic test results:_______________________________________________________________________ _________________________________________________________________________________________________________________ F. Return to Work 1. Is patient working now? Yes No If yes, are there work restrictions? 1-2 days 3-7 days Yes 8-14 days No If yes, describe the work restrictions: 15+ days Unknown at this time How long will the work restrictions apply? 2. Can patient return to work? (check only one): a. The patient cannot return to work because (explain): b. c. The patient can return to work without limitations on: _______/_______/_______ The patient can return to work with the following limitations (check all that apply) on: _______/_______/_______ Bending/twisting Lifting Sitting Climbing stairs/ladders Operating heavy equipment Standing Use of public transportation Environmental conditions Operation of motor vehicles Kneeling Personal protective equipment Use of upper extremities Other (explain): Describe/quantify the limitations: How long will these limitations apply? 1-2 days 3-7 days Yes No 8-14 days 15+ days Unknown at this time with patient's employer N/A N/A 3. With whom will you discuss the patient's returning to work and/or limitations? 4. Would the patient benefit from vocational rehabilitation? with patient This form is signed under penalty of perjury. Board Authorized Health Care Provider - Check one: I provided the services listed above. I actively supervised the health-care provider named below who provided these services. Provider's name___________________________________________________ Specialty__________________________________ Board Authorized Health Care Provider signature: / / Name Signature Specialty Date C-4.2 (1) Page 2 of 2 www.wcb.Q\JRY American LegalNet, Inc. MEDICAL REPORTING 1. IMPORTANT - TO THE ATTENDING DOCTOR This form is to be used to file re
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