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Click ‘Get Form’ to open it in the editor.
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.
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.
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.
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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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 C-4 form?
Avoid Downplaying Your Injury: Dont minimize your pain or discomfort. Statements such as Its not that bad or Im sure Ill be fine can lead to your injury being categorized as less severe than it actually is. Dont Speculate on Recovery Time: Do not make guesses about how quickly you will recover.
c4 form
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Rules and Regulations on Controlled Substances in NYS
(1) pharmacy prescription number;. (2) pharmacys national identification number;. (3) patient name;. (4) patient address, including street, city, state, ZIP
Form. Full Name. Social Security Number. (first). (mi). (last). Home Address. (number and street). (city). (zip code). (state). As an employee of Auburn
Regulation B Sample Notification Form C-4 - English
Apr 1, 2022 Regulation B Sample Form. Sample Form C-4: Notice of Action Taken and Statement of. Reasons (Counteroffer disclosure) English. Page 2. Date.
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