Doctor's Report of MMI/Permanent Impairment (Form C-4.3) is available for web submission. This form requires a User ID and Password. If you do not have a user ID and Password visit the How to Register page to learn how to apply for one.

Select Workers' Compensation Forms for Health Care Providers this will display a list of forms available for Health Care Providers to submit electronically, or on paper, you may also contact your local WCB District Office and request the paper form.

No. User IDs and passwords are created for Health Care Providers (HCP) only. The user ID and password in conjunction with the WCB Authorization Number is considered to be the legal equivalent of actually signing the form by hand. Therefore, only the actual HCP is eligible for a user ID and password.

You can use your mouse or the Tab key to navigate through the form. Some fields (indicated by a *) are always required, others will be required based on information you enter. When you finish filling out the form, select the "Submit" button. Please wait while the information is processed.  If there is a problem with the information you have provided, you will be prompted to return to the form and correct the error. If there are no errors, the completed form will be returned to your browser window in PDF format. This may take a few minutes. You can then print this form and/or save it to your computer.

Attachments may be submitted with the C-4.3.

The Workers' Compensation law requires you to maintain records of certain forms. You need to keep a copy of the Adobe PDF form that was displayed in your browser after you submitted your form. You can print the image or save a copy on your computer. Certain forms require you to also provide copies to the claimant, employer, insurance carrier, claimant representative, etc.

A PDF is a Portable Document Format, a universal file format that preserves all the fonts, formatting, graphics and color of any source document, regardless of the application and platform used to create it. It can be shared, viewed, and printed by anyone with free Adobe Reader® software.

You can get the latest Adobe Reader® from www.adobe.com

Use the search function on the Online Forms Submission page:

Log into the Medical Portal with your User ID and Password. From the Billing column, select Web Submission of Medical Forms. On the Forms for Online Submission select from the drop down list what you want to "Search By" (Last Name, Form Type, Case ID…), then enter corresponding information from the form, such as the Claimant's last name, in the 'Search For' field. Choose the Search button on the bottom of the window. A list of the forms that you have submitted will be displayed, based on the information you entered. If you want to reprint a form, select the radio button to the left of the form and then press the View PDF button to open that form in your browser window.

You will need to contact your local WCB District Office to obtain a copy of the form if:

• It has been more than 30 days since you submitted the form.
• You are unable to find the form you are looking for using the search function.

Please note: this copy will not be available for three business days from the date you submitted the form on the web.

Yes. All versions of the C-4 medical billing forms (except the C-4.3) were replaced by the required submission of the CMS-1500 form on July 1, 2022. Learn more about the CMS-1500 Initiative.