ATTENDING OPHTHALMOLOGIST'S REPORT 48 HR. INITIAL STATE OF NEW YORK WORKERS' COMPENSATION BOARD SERVICES PROVIDED UNDER WCB PREFERRED PROVIDER ORGRANIZATION (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 WCB CASE NO. CARRIER CASE NO. (IF KNOWN) INJURED PERSON EMPLOYER* (First Name) (Middle Initial) (Last Name) ADDRESS (Include Apt. No.) TELEPHONE NO. PATIENT'S BIRTH DATE INSURANCE CARRIER Indicate days of week & times (AM or PM) when you are available to testify. VFBL *If treatment was under the VFBL or VAWBL show as "Employer" the liable political subdivision and check one: VAWBL and complete Items 3-23 below. If not, complete ALL items. If you have filed a previous report, setting forth a history of the injury, enter date 1. How did injury occur? Give source of information. H I S T O R Y 2. If there are any pre-existing ocular conditions, describe specifically. D I A G N O S I S 3. Describe nature and extent of injury, including permanent ocular defects, and/or permanent facial, head or neck disfigurement, if any, due to present injury. Attach visual field test, diagram site of injury, if applicable. T R E A T M E N T I M P A I R M E N T 4. Present condition: (Amount of corrected and uncorrected vision in injured eye and all other permanent defects must be known in order to determine compensation due, if any.) (a) Acuity of central vision uncorrected: O.D._________ O.S.__________ Is condition permanent? Yes No Is loss due to present injury? Yes No Is condition permanent? Yes No Is loss due to present injury? Yes No (b) If less than 20/20, what is corrected: O.D._________ O.S.__________ (c) Lenses used for correction: O.D. ________________________________ O.S. _______________________________________ (d) Loss of binocular vision_______________________________________ Yes No Is loss due to present injury? Yes No Is condition permanent? Date of your first treatment Has patient reached maximum medical improvement? If no, 5. Dates of examinations on when will patient be seen again? which this report is based: 6. Describe treatment you have rendered and planned future treatment. If X-rays were taken, so indicate. If patient was hospitalized give name/location of hospital and dates of hospitalization. If an authorization request is required (see items 4 & 5 on reverse), check box and explain below. If additional space is necessary, attach request. 7. First day of disability, if known: 8. Is patient working? 10. Can patient do any type of work? YES YES NO NO 9. Is patient disabled from regular duties or work? YES NO If "yes" disability is: TOTAL PARTIAL If "yes" describe work capacity. 11. Diagnosis or nature of disease or injury (Relate Items 1,2,3 or 4 to Item 12E by line.) Enter ICD10 code and describe nature of injury. 1. 3. 2. 4. B 12. A I L From DD L MM I N G B Dates of Service To YY MM DD 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 C R 13. In your opinion, was the occurrence described above (or in your previous report which gave this information) the competent producing cause of the injury or disease? YES 17. Federal Tax I.D. Number SSN EIN 18. Patient's Account No. Affirmed Under Penalty of Perjury NO Amount Paid 14. Total Charges 15. (carrier use only) 16. Balance Due (carrier use only) S I G N A T U R E 19. WCB Authorization No. 20. WCB Rating Code THE INJURED WORKER SHOULD NOT PAY THIS BILL. 22. Doctor's Name, Address & Phone Number 23. Doctor's Billing Name, Address & Phone Number 21. Signature of Doctor Date SEE REVERSE SIDE FOR IMPORTANT INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com C-5 (10-15) www.wcb.ny.gov IMPORTANT - TO THE ATTENDING OPHTHALMOLOGIST 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 betwen 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. 2. 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. 3. This form must be signed by the attending doctor and must contain her/his authorization certificate number and code letters. If the patient is hospitalized, it may be signed by a licensed doctor to whom the treatment of the case has been assigned as a member of the attending staff of the hospital. 4. AUTHORIZATION FOR SPECIAL SERVICES: 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 physiotherapeutic or other procedures or to provide for special diagnostic laboratory tests costing more than $1,000, (s)he must request authorization from the self-insured employer or insurance carrier. 5. 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 6 of this form. Attach copy of request, if necessary. c. The self-insured employer or insurance carrier may have the patient examined within