C4 auth form 2026

1. Click ‘Get Form’ to open the c4 auth form in the editor.
2. Begin by filling in the WCB Case # and Claim Administrator Claim # at the top of the form. Ensure these numbers are accurate as they are crucial for processing your request.
3. In section A, enter the Patient's Name, Address, Employer Name, Date of Injury/Illness, and Social Security Number. Double-check for any typos to avoid delays.
4. Proceed to section B and input the Attending Doctor's Name, Address, NPI No., and contact details including Fax and Telephone numbers.
5. In section C, clearly specify the Authorization Requested. Indicate any Diagnostic Tests or Therapy needed and check the appropriate boxes for services requested.
6. Complete the Statement of Medical Necessity by providing a detailed explanation justifying why these services are essential for the patient’s treatment.
7. Finally, ensure that you sign and date the form before submitting it through our platform via fax or email as indicated on the Workers' Compensation Board's website.

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