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Doctors Report Of MMI-Permanent Impairment C-4.3 - New York
| Doctors Report Of MMI-Permanent Impairment Form. This is a New York form and can be used in Workers Compensation . |
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Doctor's Report of MMI/Permanent Impairment State of New York - Workers' Compensation Board C-4.3 Use this form when a patient has reached Maximum Medical Improvement and to render an opinion on permanent impairment, if any. (To report the first time you treated the patient, use Form C-4. For continuing treatment, use Form C-4.2.) 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.state.ny.us. Date(s) of Examination:_______/_______/_______ WCB Case # (if known): Carrier Case #: A. Patient's Information 1. Name: Last First MI 2. Date of injury/illness: _____/_____/_____ 3. Soc. Sec. #: Number and Street City State - - 4. Address (if changed from previous report): Zip Code 5. Patient's Account #: B. Doctor's Information 1. Your name: Last First MI 2. WCB Authorization #: 4. Federal Tax ID #: Number and Street City 3. WCB Rating Code: 5. Office address: 6. Billing Group or Practice Name: 7. Billing address: The Tax ID # is the (check one): State SSN Zip Code EIN Number and Street City State Zip Code 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 City State Zip Code 2. Carrier Code #: W 4. Diagnosis or nature of disease or injury: Enter ICD9 Code: (1) (2) Relate ICD9 codes in (1) or (2) to Diagnosis Code column below by line. From MM Dates of Service To YY MM DD Place of Service ICD9 Descriptor: Use WCB Codes Leave Blank Procedures, Services or Supplies CPT/HCPCS MODIFIER Diagnosis Code $ Charges DD YY Days/ Units COB Zip code where service was rendered Total Charge Check here if services were provided by a WCB preferred provider organization (PPO). Amount Paid (Carrier Use Only) Balance Due (Carrier Use Only) $ $ $ D. Permanent Impairment/Work Status 1. Has the patient reached Maximum Medical Improvement? 2. Is there permanent impairment? Yes No Yes No If yes, provide the date patient reached MMI:_____/_____/_____ If yes, check the boxes that apply: Schedule loss of use of member:(Identify impairment rating according to NY Impairment Guidelines and attach separate sheet for additional body parts.) Body part: ________________________________________________________________ Impairment: %________________ THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES C-4.3 (8-09) Page 1 of 2 www.wcb.state.ny.us PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION American LegalNet, Inc. www.FormsWorkFlow.com Patient's Name: Last First MI Date of injury/onset of illness:______/______/______ Describe findings and relevant diagnostic test results:_____________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Explain how impairment % was determined: ___________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Disfigurement: (Describe findings) ___________________________________________________________________________________ Non-Schedule losses: (Identify impairment rating according to NY Impairment Guidelines. Attach separate sheet for additional body parts.) Body part: ________________________________________________________ Impairment: %____________ Describe findings and relevant diagnostic test results:_____________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Explain how impairment % was determined: ___________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ For multiple impairments from an injury/illness: a. Combined aggregate impairment: %__________ b. Explain how % was determined: ___________________________________________________________________________________ _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ 3. Is patient working now? Yes at the pre-injury job Yes Yes at other employment No Not working 4. Does the patient have work limitations? Bending/twisting Climbing stairs/ladders Environmental conditions Kneeling Other (explain): Describe/quantify the limitations: If yes, check all of the following that apply: Sitting Standing Use of public transportation Use of upper extremities Lifting Operating heavy equipment Operation of motor vehicles Personal protective equipment 5. With whom have you discussed patient's returning to work and/or limitations? 6. Would patient benefit from vocational rehabilitation? Yes No with patient with patient's employer N/A If yes, explain _________________________________________ This form is signed under penalty of perjury. Board Authorized Health Care Provider signature: / C-4.3 () Page 2 of 2 Name Signature Specialty Date / www.wcb.state.ny.us American LegalNet, Inc. www.FormsWorkFlow.com MEDICAL REPORTING 1. IMPORTANT - TO THE ATTENDING DOCTOR This form is to be used to file reports in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit cases as follows: When your patient has reached Maximum Medical Improvement and to render an opinion on permanent impairment, if any. All reports are to be filed with the
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