C4 3 form 2026

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The document is a Doctor's Report (C-4.3) used for assessing Maximum Medical Improvement (MMI) and permanent impairment in workers' compensation cases. It outlines the necessary information to be provided by healthcare providers, including patient details, examination dates, diagnosis codes, and treatment plans. The report includes sections for evaluating MMI status, identifying any permanent impairments, and detailing functional capabilities. It also provides instructions for completing the form and emphasizes the importance of timely submission to avoid delays in benefits.

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Click ‘Get Form’ to open the C-4.3 form in the editor.
Begin by filling out Section A, Patient's Information. Enter the patient's name, date of birth, and address. Ensure all fields are completed accurately.
Proceed to Section B, Doctor's Information. Input your name, WCB Authorization number, and office address. This section is crucial for identifying the healthcare provider.
In Section C, Billing Information, provide details about the employer's insurance carrier and diagnosis codes. Make sure to include any relevant ICD10 codes.
Move on to Section D regarding Maximum Medical Improvement (MMI). Indicate whether the patient has reached MMI and provide the date if applicable.
Complete Section E on Permanent Impairment by answering questions about any permanent impairments and detailing body parts affected.
Finally, review all sections for accuracy before signing at the bottom of the form. Submit it promptly as instructed.

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