Workers compensation c 4 form 2026

1. Click ‘Get Form’ to open the workers compensation C-4 form in the editor.
2. Begin by filling in the patient's name, address, and Social Security number in Section A. Ensure accuracy as this information is crucial for processing.
3. Next, provide details about the attending doctor, including their name, address, NPI number, and contact information in Section B.
4. In Section C, specify the authorization request for special services. Clearly indicate any diagnostic tests or therapies required and ensure you check the appropriate boxes for authorization status.
5. Complete the Statement of Medical Necessity section by detailing why these services are essential for the patient’s treatment.
6. Finally, submit the completed form via fax or email to the insurer's designated contact as listed on the Workers' Compensation Board's website. Ensure you keep a copy for your records.

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