Form c4 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section A, which requires the patient's information. Enter the patient's name, Social Security number, mailing address, home phone number, date of birth, date of injury or onset of illness, WCB case number (if known), carrier case number, and patient account number.
3. Proceed to Section B for the doctor's information. Input your name, WCB authorization number, tax ID (either Federal or SSN), office address, billing group name, and contact numbers.
4. In Section C, complete the billing information. This includes details about the employer's insurance carrier and their address. Specify the diagnosis or nature of disease/injury along with relevant ICD9 codes and dates of service.
5. Ensure all sections are filled completely and accurately. Attach any necessary reports for services provided before submitting promptly to the Board and other relevant parties.

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