Please Note: All versions of the C-4 medical billing forms (except the C-4.3) and the OT/PT-4 were replaced by the required submission of the CMS-1500 form on July 1, 2022. Learn more about the CMS-1500 Initiative.
The health care provider must be authorized by the NYS Workers' Compensation Board.
A user ID and password is required to submit these online forms. This is the same user ID and password used to access the Board's Medical Portal. When a form listed below is filed with the Board, it is electronically signed by a Board authorized health care provider in compliance with the New York State Electronic Signatures and Records Act (ESRA) and its accompanying regulation (9 NYCRR 540).
To submit a form, log in to the Medical Portal and select the link for Web Submission of Medical Forms.
After successful submission, a confirmation of receipt by the Board and printable PDF version of the form will appear in your web browser. You will need to keep a copy of the PDF and provide copies to other interested parties.
| Form Number | Form Title | Who Can Submit | Comments |
|---|---|---|---|
| C-4.3 | Doctor's Report of MMI/Permanent Impairment |
|
Use this form (1) When rendering an opinion on MMI and/or permanent impairment; or (2) In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent impairment. |
If the form you are looking for is not available for Web Submission, you may print the paper version of the form from our list of common forms. For the CMS-1500, contact the U.S. Government Printing Office at 1-866-512-1800, local printing companies in your area, and/or office supply stores; or contract with an XML Submission Partner to electronically submit the bill.