STATE OF NEW YORK WORKERS' COMPENSATION BOARD ATTENDING DOCTOR'S REQUEST FOR MEDICAL AUTHORIZATION DETERMINATION INSTRUCTIONS: This form may be used by an attending doctor whenever a carrier or self-insured employer has not responded within 30 days to the doctor's request for authorization for special services costing more than $1,000. File this form with the Workers' Compensation Board at the address on reverse, and simultaneously with the claimant's workers' compensation insurance carrier. Complete all items. Incomplete forms will not be processed. All of the following conditions must be met before you file this form: 1. You have contacted the carrier or self-insured employer by telephone and requested authorization for special services costing more than $1,000. 2. You have sent the carrier or employer and filed a copy with the Board Form C-4 with item 4 checked "Yes" requesting authorization for special services costing more than $1,000. 3. At least thirty (30) days have elapsed since your initial telephone contact with no response from the carrier or selfinsured employer. Please note that any response from the carrier, such as a denial of your request, precludes the Board from issuing a determination authorizing such special services. 4. Please complete items 1. through 22. below, making sure that the doctor's signature and the signature of the person certifying the mailing date are original. Signatures in items 21 & 22 must be in ink only, blue ballpoint pen, if possible. 1. WCB CASE NO. 2. CARRIER CASE NO. (IF KNOWN) 3. DATE OF INJURY 4. & TIME 5. ADDRESS WHERE INJURY OCCURRED (CITY, TOWN OR VILLAGE) 6. INJURED PERSON'S SOCIAL SECURITY NUMBER 7. INJURED PERSON (First Name) (Middle Initial) (Last Name) 8. ADDRESS (Include Apt. No.) 9. TELEPHONE NO. 10. EMPLOYER* 11. PATIENT'S DATE OF BIRTH 12. INSURANCE CARRIER 13. SUPERVISING PHYSICIAN (if any) 14. *If treatment was under the VFBL or VAWBL show as "Employer" the liable political subdivision and check one: VFBL VAWBL 15. SPECIAL SERVICES REQUESTED 16. VERBAL REQUEST FOR AUTHORIZATION FROM CARRIER: a. NAME OF EMPLOYEE CONTACTED__________________________________________________________________________ b. DATE OF TELEPHONE CALL REQUESTING AUTHORIZATION__________________ c. TELEPHONE NO._________________ 17. DATE FORM C-4 WAS SENT REQUESTING AUTHORIZATION 18. DOCTOR'S NAME AND ADDRESS 19. DOCTOR'S TELEPHONE NUMBER 20. DOCTOR'S WCB AUTHORIZATION NUMBER 21. I SUBSCRIBE AND AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THESE STATEMENTS ARE TRUE AND CORRECT. DOCTOR'S SIGNATURE_________________________________________________ DATE_________________________________ (ink only -- use blue ballpoint pen if possible) 22. I hereby certify that a copy of this form was mailed to the carrier/self-insured employer named above on____________. Signature______________________________________________________ (ink only -- use blue ballpoint pen if possible) MD-1 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com 12 NYCRR 325-1.4 Authorization for Special Services (a)(1) When it is necessary for the attending physician to engage the services of a specialist, consultant, or a surgeon, or to provide for X-ray examinations or occupational therapy or physical therapy or special diagnostic laboratory tests costing more than $1,000, he or she must request and secure authorization from the employer or insurance carrier or the chair, by setting forth the medical necessity of the special services required. For example, when the total fees for occupational or physical therapy treatment approach the sum of $1,000, the physician shall file an additional C-4 report and request authorization as prescribed in subdivision (5) of section 13-a of the Workers' Compensation Law. (2) This section also applies to hospitals, specialists, consultants and surgeons, who are actually engaged to perform such services. (3) Such request for authorization should be by telephone to the employer or carrier and later confirmed by letter. (4) In order to process such requests expeditiously and within the time limits specified hereunder, the insurance carrier shall designate a qualified employee in its office, and the self-insured employer shall designate a qualified employee in its office or an authorized employee of its licensed representative, to receive and act upon such requests. To assure compliance within the time limits prescribed, qualified persons shall be specially designated, within each office of the Workers' Compensation Board, to deal with complaints relative to such authorizations. (5) In response to requests for authorization, the self-insured employer or insurance carrier may have the patient examined within four business days if patient is hospitalized or thirty days if patient is not hospitalized, by an appropriate medical board-certified specialist who is also authorized in such specialty, by the chair, to treat workers' compensation claimants. If such specialist is not available, consultation may be rendered by an authorized physician who is acceptable to both the self-insured employer or insurance carrier and the physician requesting authorization, or in the event the parties cannot agree, a physician may be selected by the chair. (6) The self-insured employer or insurance carrier shall grant or deny the requested authorization within four working days if the claimant is hospitalized, or within thirty days if the claimant is not hospitalized, by orally notifying the physician or hospital of its action. It shall confirm such action in writing by sending a notice to the physician, claimant's attorney or licensed representative and/or hospital within five days after the examination of the claimant when the four-day provision applies. When the 30 day provision applies, the written confirmation shall be mailed within such period. Written notice of denial must be based on a conflicting second opinion rendered by a physician authorized to treat workers' compensation claimants. Nothing herein shall relieve the carrier from complying with the provisions of 12 NYCRR 300.23. (7) If such authorization or denial is not forthcoming within four working days if patient is hospitalized, the chair may issue an order, after investigation, authorizing the special services, on the ground that such authorization has been unreasonably withheld and the employer or carrier shall be liable for the payment for such special services and investigation. If such authorization or denial is