Medical Narrative Report Template For CMS-1500

MEDICAL NARRATIVE REPORT TEMPLATE FOR CMS-1500. This is a standardized form used by healthcare providers to submit required medical documentation in workers’ compensation, volunteer firefighter, or volunteer ambulance worker benefit cases. Issued under the New York State Workers’ Compensation Board (WCB), this template ensures compliance with CMS-1500 reporting standards by capturing key elements: Work Status, Causal Relationship, and Temporary Impairment Percentage. Providers must complete identifying fields for the patient, provider, date of injury, and treatment details, then attach a supporting narrative with examination findings. Reports must be filed within 48 hours of initial treatment and every 15 to 90 days thereafter during continuing care. The completed form must be signed by the provider listed in field 31 of the CMS-1500. HIPAA exemptions apply under WCL 13-a(4)(a). www.FormsWorkflow.com