Home
Forms Library
C 4 auth formDocHubcom 2014

C 4 auth formDocHubcom 2014-2026

c 4 auth formDocHubcom 2014 Preview on Page 1

See details

4.4 out of 5

588 votes

The document is a request form for authorization of special medical services related to workers' compensation cases in New York. It outlines the necessary information required from the attending doctor, including patient details, injury specifics, and the requested services that exceed $1,000 or require pre-authorization. The form also details the response obligations of the insurance carrier or self-insured employer regarding approval or denial of the request, along with guidelines for medical necessity and communication protocols.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out c 4 auth formDocHubcom 2014 with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the c 4 auth form in the editor.
Begin by entering the WCB Case Number and Carrier Case Number at the top of the form.
Fill in the Patient's Name, Social Security Number, and Address. Ensure all fields are completed accurately.
Provide details about the Employer's Name and Address in the designated sections.
Enter the Attending Doctor's Name, Address, WCB Authorization No., Telephone No., and Fax No. in section B.
In section C, specify the Authorization Requested for special services costing over $1,000. Check appropriate boxes for Diagnostic Tests, Therapy, or Surgery as applicable.
Complete the Statement of Medical Necessity section by detailing why these services are required.
Sign and date the form at the bottom to certify your request before submitting it through our platform.

Start using our platform today to streamline your document editing and submission process for free!

See more c 4 auth formDocHubcom 2014 versions

We've got more versions of the c 4 auth formDocHubcom 2014 form. Select the right c 4 auth formDocHubcom 2014 version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (91 Votes)
2018	4.4 Satisfied (269 Votes)
2014	4.4 Satisfied (588 Votes)
2013	4.4 Satisfied (239 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What do I need to sign my c 4 auth formDocHubcom 2014 electronically?

Electronic document signing requires a software solution that works in compliance with data security and eSignature laws. DocHub is a perfect tool for that, since it fulfills all the above mentioned requirements. Whatever method you prefer to sign your c 4 auth formDocHubcom 2014 in DocHub, your electronic signature will be legally binding and court-admissible.

How do you edit c 4 auth formDocHubcom 2014 on Android?

Document editing with DocHub is equally convenient on desktop and mobile devices. You only need an internet browser to revise your c 4 auth formDocHubcom 2014 on Android. Open our site and sign in to access the instruments you require. Add your document and introduce your intended changes. Next, you can keep your form in your document storage or send it out immediately.

What is a C-4 form?

The C-4 form will be used by the insurer in their decision making process as to whether to accept or deny the workers compensation claim. For example, insurance adjusters look at whether the injured worker reported their injury timely to their supervisor.

What is a Texas C-4 form?

Wages List (Form C-4) includes the employee names, Social Security numbers and wage amounts paid in the quarter. TWC Rules 815.107 and 815.109 require all employers to report wages and pay unemployment taxes electronically.

What is form C4?

What Prior Authorization Really Means in Workers Compensation. In simple terms, prior authorization is a request for the insurance carrier to approve a specific treatment before it happens. In most workers compensation cases, medical care isnt immediately covered unless its been cleared through this step.

What is a C4 form?

If youve been injured on the job, you may be entitled to workers compensation benefits. In order to receive these benefits, youll need to fill out a C4 form. This form is used to report your injury to your employer and to the workers compensation insurance carrier.

What not to say to Workmans Comp?

What Not to Say to a Workers Comp Doctor Avoid Downplaying Your Injury: Dont minimize your pain or discomfort. Dont Speculate on Recovery Time: Do not make guesses about how quickly you will recover. Stay Away from Absolute Statements: Do not use words like always or never when describing your symptoms.

C 4 auth formDocHubcom 2014-2026

Here's how it works

How to use or fill out c 4 auth formDocHubcom 2014 with our platform