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OT/PT-4 (6-04) - WorkCompCentral

OT/PT-4 (6-04) - WorkCompCentral 2025

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4.2 out of 5

56 votes

The document is a report form for occupational and physical therapists to file initial and progress reports related to workers' compensation cases in New York. It outlines the necessary information to be provided, including patient details, diagnosis, treatment plans, and billing information. The form must be completed within specified timeframes (48 hours for initial reports, 15 days for subsequent reports) and submitted to the Workers' Compensation Board and relevant parties. It also includes important instructions regarding authorization for services and patient rights.

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Click ‘Get Form’ to open the OT/PT-4 (6-04) in our editor.
Begin by entering the WCB Case Number and the Injured Person's details, including their name, date of injury, and social security number. Ensure all fields are completed accurately.
In the 'Diagnosis' section, provide a detailed diagnosis as per the referring physician's notes. If there is a history of pre-existing conditions, describe them specifically.
Indicate whether the referral was for evaluation only, treatment only, or both. Complete the relevant sections based on your selection.
Fill in the dates of service and any charges associated with treatments provided. Make sure to include CPT/HCPCS codes where applicable.
Finally, sign and date the form at the bottom. Ensure that your license number and contact information are included before submitting.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (170 Votes)
2015	4.4 Satisfied (554 Votes)
2011	4.3 Satisfied (59 Votes)
2004	4.2 Satisfied (56 Votes)

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