C 4 0 2026

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The document is a C-4 form used by healthcare providers to report the initial treatment of a patient in workers' compensation cases. It requires detailed information about the patient, employer, doctor, billing, and the nature of the injury or illness. The form emphasizes the importance of timely submission to avoid delays in treatment payments and wage loss benefits. It includes sections for patient history, examination findings, proposed treatment plans, work status, and necessary follow-up actions.

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Click ‘Get Form’ to open the C-4 form in the editor.
Begin by filling out Section A, which includes the patient's information. Ensure you provide the patient's name, Social Security number, and contact details accurately.
Proceed to Section B for employer information. Enter the employer's name and address where the injury occurred.
In Section C, input your details as the treating doctor, including your name, WCB authorization number, and office address.
Complete Section D by detailing billing information and diagnosis codes related to the patient's condition.
Fill out Sections E through H with relevant medical history, examination findings, and proposed treatment plans.
Finally, review all sections for completeness before submitting the form electronically through our platform for prompt processing.

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