IMPORTANT: PLEASE READ CAREFULLY THE FOLLOWING INFORMATION FOR DETERMINING HOW TO FIND INSURER/SELF-INSURER CONTACTS C-4 AUTH, ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION AND INSURER'S RESPONSEThis form requires the name and fax number or email address of the insurer's designated contactlisted on the Workers' Compensation Board's website.Insurer/Self-Insurer's designated contact information is available online at: wcb.ny.gov/attending-doctors-request-authorizationC-4 AUTH (7-18) COVER SHEETThe undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to the Medical Treatment Guidelines. Do NOT use this form for injuries/illnesses involving the Mid and Low Back, Neck, Knee, Shoulder, Carpal Tunnel Syndrome and Non-Acute Pain, except for the treatment/procedures listed below under Medical Treatment Guideline Procedures Requiring Pre-Authorization. Please use the appropriate Medical Treatment Guideline form if any other procedure/test is being requested. Authorization Requested: Insurer Response: if any service is denied, explain on reverse. Diagnostic Tests: Therapy (including Post Operative): Surgery: Treatment: Medical Treatment Guidelines Procedures Requiring Pre-Authorization (Complete Guideline Reference for each item checked, if necessary. In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines.)............................................................................. 1. ........................................................... 2. ................................................................................ 3. .................................................................................... 4. ............................................... 5. ................................................................. 10. ................................................................ 6. ................................................12. ............9. ATTENDING DOCTOR'S REQUEST FOR AUTHORIZATION AND INSURER'S RESPONSE Answer all questions fully on this reportC-4AUTH AUTHORIZATION REQUEST FirstMILast Number and StreetCityStateZip CodeNumber and StreetCityStateZip CodeNumber and StreetCityStateZip CodeNumber and StreetCityStateZip Code B a 4 E - E - B a i 7 E - B a i 7 E - a E - P 1 G - K f 1 D - K 1 D - K D - K 2 F - -A.C.B. Patient's Name: Address: Type of Surgery (Describe, include use of hardware/surgical implants) 1.Lumbar Fusions 2.Artificial Disk Replacement 5.Electrical Bone Growth Stimulators 10.Spinal Cord Stimulators 6.Osteochondral Autograft 7.Autologous Chondrocyte Implantation 12.Second or Subsequent Procedure 9.Knee Arthroplasty (total or partial knee joint replacement) 8.Meniscal Allograft Transplantation 4.Kyphoplasty 3.Vertebroplasty Granted Granted w/o Prejudice Denied Other Denied Granted w/o Prejudice Granted Denied Granted Denied Granted w/o Prejudice Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied Granted w/o Prejudice Granted Other Granted Granted w/o Prejudice Denied Granted Granted w/o Prejudice Denied .........................................11. 11.Intrathecal Drug Delivery (pain pumps) Denied Granted w/o Prejudice Granted Denied Granted w/o Prejudice Granted Radiology Services (X-Rays, CT Scans, MRI) indicate body part: Physical Therapy: Other times per week for weeks Granted Granted w/o Prejudice Denied Occupational Therapy: times per week for weeks.................................................8. .............................................7. WCB Case #: Date of Injury/Illness: Claim Administrator Claim (Carrier Case) #:-2GPf C-4AUTH (-18) Page 1 of 2 Social Security No.: Employer Name: Address: Address: Insurer Name: Address: Attending Doctor's Name: Fax No.: Telephone No.: NPI No.: - Individual Provider's WCB Authorization No.: American LegalNet, Inc. www.FormsWorkFlow.com Pursuant to 12 NYCRR 325-1.4(a)(1), it is the treating provider's burden to set forth the medical necessity of the special services required. Failure to do so may delay the authorization process. Your explanation of medical necessity must provide the basis for your opinion that the medical care you propose is appropriate for the patient and is medically necessary at this time.Providers must complete Part A below indicating that the request was sent to the insurer/self-insurer's designated fax or email address (see Board's URL address below*), unless the provider is not equipped to send or receive email or fax (complete "C" below). If the request was also sent to an additional fax or email address provided by the insurer, complete Part B below.Response Time and Notification Required: Failure to Timely Respond to Form C-4 AUTH: The special service(s) for which authorization has been requested will be deemed authorized by Order of the Chair if the self-insured employer/insurer fails to respond within 30 days (35 days if C-4AUTH is mailed with return receipt requested). An Order of the Chair is not subject to an appeal under Section 23 of the Workers' Compensation Law. REASON FOR DENIAL(S), IF ANY. (ATTACH OR REFERENCE CONFLICTING SECOND MEDICAL OPINION AS EXPLAINED ABOVE.)I certify that the self-insured employer/insurer telephoned the office of the health care provider listed above within the response time-frame indicated above and advised that the self-insured employer/insurer had either granted or denied approval for the special services for which authorization was sought, as indicated above, on the date below: and I certify that copies of this form were emailed, faxed, or mailed to the treating provider, the claimant (patient), the claimant's legal representative, if any, the Workers' Compensation Board and all parties of interest on the date below: SELF-INSURED EMPLOYER / INSURER RESPONSE TO AUTHORIZATION REQUEST STATEMENT OF MEDICAL NECESSITY The self-insured employer/insurer must respond to the authorization request orally and in writing via email, fax or regular mail with confirmation of delivery within 30 days. The 30 day time period for response begins to run from the completion date of this form if emailed or faxed, or the completion date plus five days if sent via regular mail. The written response shall be on a copy of this form completed by the treating provider seeking authorization and shall clearly state whether the authorization has been granted, granted without prejudice, or denied. Authorization can only be granted without prejudice when the compensation case is controverted or the body part has not yet been established. Authorization without prejudice shall not be construed as an admission that the condition for which these services are required is compensable or the employer/insurer is liable. The employer/insurer shall not be responsible for the payment of such services until the question of compensability and liability is resolved. Written response must be sent to the treating provider, claimant (patient), claimant's legal counsel, if any, the Workers' Compensation Board and any other parties of interest. Denial of the Request for Authorization of a Special Service: A denial of authorization of a special service must be based upon and accompanied by a conflicting second opinion rendered by a physician authorized to conduct IMEs, or record review, or qualified medical professional, or a physician authorized to treat workers' compensation claimants. (If authorization is denied in a controverted case, the conflicting second opinion must address medical necessity only.) When denying authorization for a special service, the employer/insurer must also file with the Board within 5 days of such denial Form C-8.