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A Guide to Deciphering New York Workers’€™ Compensation Doctor Forms

A New York workers’ compensation claim will include the submission of requisite physician forms and doctor statements. Every medical report must be completed and signed by a New York Workers’ Compensation Board-authorized healthcare provider. Physicians must complete and submit forms directly to the Board.

There exist several dozen types of forms related to a worker’s injury. Not all forms are applicable in every work injury case. Missing or incomplete medical records may delay a claim or result in the denial of workers’ compensation benefits.

Below is an overview of some of the most common types of required doctor’s forms and what they include:

  • Doctor’s Initial Report (also known as C-4) – This report must be completed within the first 48 hours of initial treatment for a work injury. The report includes details about your symptoms, such as whether you experience swelling, weakness, pain, numbness or other signs of discomfort. It also includes a description of your injuries, such as whether it was a crush injury, needle stick, spinal cord injury or inhalation exposure. The physician should include diagnosis, prognosis, treatment and whether your injuries are consistent with your version of events.
  • Doctor’s Progress Report (also known as C-4.2) – This report is completed at the 15-day follow-up after your initial treatment. A new C-4.2 will be completed at each follow-up visit – provided there is no more than 90 days between appointments. The report includes information about your progression and how the injury affects other body areas (for instance, has a knee injury affected your gait and resulted in back pain?). The report also details recommended diagnostic testing and whether you are ready to return to work and if so, any limitations.
  • Doctor’s Narrative Report (also known as EC-4NARR) – The physician may submit a narrative report at the initial treatment and for all follow-up evaluations. This is an online submission and requires registration with NY.gov.  
  • Medical Proof of Change in Condition in Support of Application for Reopening (also known as C-27) – A physician may file this report when there is new medical evidence to suggest reopening a previously closed workers’ compensation claim. This outlines your condition at the time of the case closing and present symptoms or limitations that support reopening the claim.
  • Record of Percentage of Hearing Loss (also known as C-72.1) – A medical specialist may submit this form at the conclusion of an audiometric battery of tests. This is used to illustrate what portion of special sensory loss you have experienced as the result of an on-the-job incident.
  • Practitioner’s Report of Functional Capacity Evaluation (also known as FCE-4) – Completed by physical or occupational therapist when you seek to return to work or begin vocational rehabilitation.
  • Practitioner’s Report of Independent Medical Examination (also known as IME-4) – Completed when an Independent Medical Examination is ordered in a workers’ compensation claim.

Other doctors’ forms address specific types of workplace injuries, such as vision loss or psychological distress. Others help providers seek payment from insurance companies. A workers’ compensation lawyer can talk to you about which forms are relevant to your claim in New York.

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