C4 3 form 2026

1. Click ‘Get Form’ to open the C-4.3 form in the editor.
2. Begin by filling out the Patient's Information section, including the patient's name, date of birth, and address. Ensure all fields are completed accurately.
3. Proceed to the Doctor's Information section. Enter your name, WCB Authorization number, and office address. This information is crucial for proper identification.
4. In the Billing Information section, provide details about the employer's insurance carrier and any relevant diagnosis codes. Make sure to include accurate ICD10 codes.
5. Complete Section D regarding Maximum Medical Improvement (MMI). Indicate whether the patient has reached MMI and provide necessary details if not.
6. Fill out Section E on Permanent Impairment/Work Status. Choose between scheduled or non-scheduled losses based on your assessment of the patient's condition.
7. Finally, review Section F for Functional Capabilities/Exertional Abilities. Assess and document the patient's functional capacities accurately before signing off on the form.

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