Instructions
- Please allow 15 minutes to complete the application.
- The application must be completed in one sitting. You cannot save an application that is in progress and return at a later time to complete it. You will lose the information that you entered and will need to start over.
- The information that appears in the electronic application form corresponds to the provider type you selected when you signed up to access the Medical Portal.
- When you attach your application, a copy will be emailed to you at the email address provided on your application.
- Once your application has been reviewed by the Board, you will receive an email notification with the Board’s decision.
Checklist of information or attachments* needed to complete the application:
- All providers must take the Workers’ Compensation Board’s training for their provider type
- All providers must attach a Curriculum Vitae/Resume – information to include in this document: Name, NYS license number, graduate and post graduate education, additional academic training/certifications, Board Certification, Specialty/Sub specialty, professional memberships and experience
- Attach Certificate of Board Certification (if applicable)
- Physician Assistants must attach a Supervising Physician Affirmation form, signed by the Board authorized supervising physician.
- Attach Disciplinary action documents (if applicable)
- Individual NPI
- Provider’s email address – used for Board correspondence (Use of Health Care Provider Emails)
- Mailing address – used for Board correspondence
- Practice name and address(es) – displayed on the Board’s Provider Search page
- Contact address – used to schedule independent medical examinations
*Attachments must be in PDF format. The filename must only contain letters and numbers, no special characters including parenthesis, dashes or underscores. The size per attachment cannot exceed 5 MB. Use the paperclip icon located in the purple bar at the top right of your screen in the application to attach a document.
Due to scheduled system maintenance, the Initial Authorization Application will not be available between 11 pm Fridays and 7:30 am Saturdays.