ATTENDING PSYCHOLOGIST'S REPORT 48 HR. INITIAL WCB CASE NO. STATE OF NEW YORK WORKERS' COMPENSATION BOARD SERVICES PROVIDED UNDER WCB PREFERRED PROVIDER ORGANIZATION (PPO) PROGRAM? YES NO 15 DAY INITIAL 90 DAY PROGRESS SEE ITEM 1 ON REVERSE FOR FILING INSTRUCTIONS DATE OF INJURY & TIME PLEASE TYPE ALL INFORMATION - COMPLETE ALL ITEMS ADDRESS WHERE INJURY OCCURRED (CITY, TOWN OR VILLAGE) INJURED PERSON'S SOCIAL SECURITY NUMBER TELEPHONE NO. CARRIER CASE NO. (IF KNOWN) 10am INJURED PERSON EMPLOYER* INSURANCE CARRIER REFERRING PHYSICIAN TELEPHONE NO. (First Name) (Middle Initial) (Last Name) ADDRESS (Include Apt. No.) PATIENT'S DATE OF BIRTH *If treatment was under the VFBL or VAWBL show as "Employer" the liable political subdivision and check one: If you have filed a previous report, setting forth a history of the injury, enter its date 1. Describe incident or occupational history that precipitated onset of related symptoms: VFBL VAWBL and complete Items 3 to 18. If not, complete ALL items. H I S T O 2. Has patient given any history of pre-existing psychological impairment? If so, describe specifically. R Y Evaluation Only (Complete item a) Treatment Only (Complete item b-1,2) Evaluation and Treatment (Complete items a and b-1,2) E V a. Your evaluation: A L U A T I b. (1) Patient's condition and progress: O N / T R E b. (2) Treatment and planned future treatment. If an authorization request is required (see items 4 & 5 on reverse), check box and explain below. If additional space is A necessary, please attach request. T M E Date of First Visit Yes No If yes, when: Will patient be seen again? N 4. Date(s) of visits on which this report is based Yes No If no, was patient referred back to attending doctor: T 5. Is patient working? CR R E M A R K S 3. Referral was for: Yes No If yes, date(s) patient: resumed limited work of any kind resumed regular work Yes No 6. Was the occurrence described above (or in your previous report) the competent producing cause of the injury or disability (if any) sustained? 7. Enter here additional pertinent information 8. Diagnosis or nature of disease or injury (Relate Items 1,2,3 or 4 to Item 9E by line.) Enter ICD10 code and describe nature of injury. 1. 2. B 9. MM From DD 3. 4. A Dates of Service To YY MM DD I L L I N G B YY C D (USE WCB CODES) E Diagnosis Code F $ Charges G H I Zip Code Where Service was Rendered Place Leave of Blank Service Procedures, Services or Supplies (Explain Unusual Circumstances) CPT/HCPCS MODIFIER Days or COB Units F O R M S I G N A T U R E 10. Federal Tax I.D. Number SSN EIN 11. WCB Authorization Number Affirmed Under Penalty of Perjury 12. Patient's Account Number 13. Total Charges 14. Amt. Paid (carrier use only) 15. Bal. Due (carrier use only) 17. Psychologist's Name, Address & Phone No. 18. Billing Name, Address & Phone Number 16. Signature of Treating Psychologist Date American LegalNet, Inc. www.FormsWorkFlow.com THE INJURED WORKER SHOULD NOT PAY THIS BILL. www.wcb.ny.gov PS-4 (10-15) SEE REVERSE SIDE FOR IMPORTANT INFORMATION IMPORTANT TO THE PSYCHOLOGIST 1. This form is to be used to file reports in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit cases as follows: 48 HOUR INITIAL REPORT - File this form, complete in all details, within 48 hours after you first render treatment. 15 DAY INITIAL REPORT - File this form within 15 days after you first render treatment. 90 DAY PROGRESS REPORT - Following the filing of the 15 day Initial Report, file this form and thereafter during continuing treatment without further request, when a follow-up visit is necessary, except the intervals between reports shall be no more than 90 days. All reports are to be filed with the Workers' Compensation Board, the workers' compensation insurance carrier (or self-insured employer), and if the patient is represented by an attorney or licensed representative, with such representative. If the claimant is not represented, a copy must be sent to the claimant. Please ask your patient for his/her WCB Case Number and the Insurance Carrier's Case Number, if they are known to him/her, and show these numbers on your reports. In addition, ask your patient if he/she has retained a representative. If so, ask for the name and address of the representative. You are required to send copies of all reports to the patient's representative, if any. This form must be signed by the psychologist and must contain his/her authorization number, address and telephone number. AUTHORIZATION FOR SPECIAL SERVICES - Prior authorization for procedures enumerated in Section 13-a (5) of the Workers' Compensation Law costing more than $1,000 or those procedures requiring pre-authorization pursuant to the Medical Treatment Guidelines, must be requested from the self-insured employer or insurance carrier. In addition, authorization must be requested for any biofeedback treatments, regardless of the cost, or any special diagnostic laboratory tests which may be performed by psychologists. Where a claimant has been referred by an authorized physician to a psychologist for evaluation purposes only and not for treatment, prior authorization must be requested if the cost of consultation exceeds $1,000. Prior authorization is not necessary if the procedure/treatment is consistent with the Medical Treatment Guidelines. AUTHORIZATION MUST BE REQUESTED AS FOLLOWS: a. Telephone the self-insured employer or insurance carrier, explain the need for the special services, and request the necessary authorization. b. Confirm the request in writing, setting forth the medical necessity for the special services in item 3b(2) on this form. Attach copy of request, if necessary. c. The self-insured employer or insurance carrier may have the patient examined within 4 working days of the request for authorization, if the patient is hospitalized, or within 30 calendar days if the patient is not hospitalized. d. If authorization or denial is not forthcoming within 30 calendar days, notify the nearest office of the Workers' Compensation Board. LIMITATION OF PSYCHOLOGY TREATMENT - Treatment by a psychologist is limited as defined in Article 153 of the Education Law, in the Workers' Compensation Law, and the Rules of the Chair relative to Psychology Practice. HIPAA Notice - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier