New York > Workers Compensation
Attending Doctors Request For Authorization And Carriers Response C-4 AUTH - New York
| Attending Doctors Request For Authorization And Carriers Response Form. This is a New York form and can be used in Workers Compensation . |
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ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION AND CARRIER'S RESPONSE State of New York - Workers' Compensation Board Answer all questions fully on this report C-4 AUTH WCB Case Number: Carrier Case Number: Date of Injury: A. Patient's Name: ......................................................................................................................................Social Security No.: .................................................. First MI Last Address: .................................................................................................................................................................................................................................... Number and Street City State Zip Code Employer's Name: ..................................................................................................................................................................................................................... Address: .................................................................................................................................................................................................................................... Number and Street City State Zip Code Insurance Carrier's Name: ........................................................................................................................................................................................................ Address: .................................................................................................................................................................................................................................... Number and Street City State Zip Code B. Attending Doctor's Name: ......................................................................................................................................................................................................... Address: ................................................................................................................................................................................................................................... Number and Street City State Zip Code Provider's Authorization No.: .................................................Telephone No.: .................................................. Fax No.: ....................................................... C. AUTHORIZATION REQUEST The undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to the Medical Treatment Guidelines. Do NOT use this form for injuries/illnesses involving the Mid and Low Back, Neck, Knee, and Shoulder; except for the treatment/procedures listed below under Medical Treatment Guideline Procedures Requiring Pre-Authorization. Please use the appropriate Medical Treatment Guideline form if any other procedure/test is being requested. Authorization Requested: Diagnostic Tests: Radiology Services (X-Rays, CT Scans, MRI) indicate body part: Other Therapy (including Post Operative): Physical Therapy: OccupationalTherapy: Other Surgery: Type of Surgery (Describe, include use of hardware/surgical implants) Treatment: Other times per week for times per week for weeks weeks Carrier Response: if any service is denied, explain on reverse. Granted Granted Granted Granted Granted Granted Granted Granted Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Denied Denied Denied Denied Denied Denied Denied Denied Medical Treatment Guidelines Procedures Requiring Pre-Authorization (Complete Guideline Reference for each item checked, if necessary. In first box, indicate body part: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines.) 1. Lumbar Fusions B-E B-E B-E 7 7 a 4 a -E a i ............................................................................. 1. ........................................................... 2. ................................................................................ 3. -E i a Granted Granted Granted Granted Granted Granted Granted Granted Granted Granted Granted Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Granted w/o Prejudice Denied Denied Denied Denied Denied Denied Denied Denied Denied Denied Denied 2. Artificial Disk Replacement 3. Vertebroplasty 4. Kyphoplasty i .................................................................................... 4. ............................................... 5. 5. Electrical Bone Growth Stimulators 6. Spinal Cord Stimulators 7. Osteochondral Autograft B - E 10 a ................................................................. 6. K-D1 f ................................................................ 7. 8. Autologus Chondrocyte Implantation K - D 1 .............................................8. 9. Meniscal Allograft Transplantation .................................................9. 10. Knee Arthroplasty (total or partial knee joint replacement) K - F 2 ............10. ................................................11. K-D 11. Second or Subsequent Procedure C-4AUTH (2-13) Page 1 of 2 www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com STATEMENT OF MEDICAL NECESSITY Pursuant to 12 NYCRR 325-1.4(a)(1), it is the attending physician's burden to set forth the medical necessity of the special services required. Failure to do so may delay the authorization process. Date of service of supporting medical in WCB Case File: A. By fax on (date) B. By telephone on (date) and e-mailed/faxed/mailed on (date) Provider's Signature: to (person contacted) to (person contacted) (If not already in file, supporting medical must be attached.) I certify that I am making the above request for authorization. This request was made to the insurance carrier/self-insurer: (Complete A or B) A copy of this form was sent to the Board on the date below. Date: D. SELF-INSURED EMPLOYER / CARRIER RESPONSE TO AUTHORIZATION REQUEST Response Time and Notification Required: The self-insured employer/carrier must respond to the authorization request or
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