Please Note: 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.
To submit the web version of the C-4.3, the health care provider must be authorized by the NYS Workers' Compensation Board.
The Doctor's Report of MMI/Permanent Impairment (Form C-4.3) is used (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. It can be submitted by a Physician, Chiropractor, Podiatrist, Psychologist, Nurse Practitioner, or Licensed Clinical Social Worker
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.
If you submit a form online, DO NOT mail a duplicate paper form to the Board.
Features
Save Form Data
The Load Previously Saved Data and Save Data buttons, allow data from the form to be saved on your computer. You can then use the saved data to pre-populate fields the next time you submit the form. This may significantly reduce the amount of duplicate data entry required.
Attach a Document
You can attach documents to be submitted with the form.
Confirmation of Submission to the Board
After the Board receives your form, a non-editable PDF version of the form will appear in your web browser. The first page contains a confirmation that your form was successfully submitted to the Board and the date. This PDF should be saved for your records and used to send copies of the form and any attachments to required parties. DO NOT MAIL THIS FORM TO THE BOARD.
If you have problems submitting forms or questions please direct them to the WCB Online Services Technical Support Unit.
Forms may be submitted 24 hours a day. However, there are times when the forms may not be available. Please review the Board's Online Services Availability. Select Claims Web Forms Submissions for specific information. If you are experiencing problems you should check these web pages before contacting our WCB Online Services Technical Support Unit.