STATE OF NEW YORK WORKERS' COMPENSATION BOARD NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 CARRIER'S/SELF -INSURED EMPLOYER'S OBJECTION TO ATTENDING DOCTOR'S REQUEST FOR MEDICAL AUTHORIZATION DETERMINATION WCB Case Number Carrier Case Number Carrier Code Date of Injury Social Security Number Name Address Claimant Employer Carrier Representative, If Any Medical Provider Requesting Authorization on Form MD -1 Insurance Carrier/Self-Insured Employer making objection: Date Form MD -1 Mailed: Basis for Objection: Signature:________________________________ Tel. No.: (Ink only - Use blue ballpoint pen if possible.) Date: Signer's Name and Title (Please Print):________________________________________________ TO THE SIGNER: The original should be sent directly to the Workers' Compensation Board at the address shown at the top of this form. A copy of this objection must be sent to all parties in interest and the medical provider who requested authorization. Complete the Affidavit or Affirmation of Service on the reverse side of this form. MD -3 (1-11) www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com AFFIRMATION OF SERVICE STATE OF NEW YORK, COUNTY OF _________________________ ss: I, the undersigned, am an attorney admitted to practice in the courts of New York State, and on __________________, I served a date true copy of this form and attachments in the following manner (check one): Service by Mail By mailing the same in a sealed envelope, with postage prepaid thereon, in a post -office or official depository of the U.S. Postal Service within the State of New York, addressed to the last known address of the addressee(s) as indicated below: Personal Service By delivering the same personally to the persons and at the addresses indicated below: I affirm that the foregoing statements are true under penalties of perjury. _____________________________________________________ Signature Dated: _________________ _____________________________________________________ Signer's Name (Please Print) AFFIDAVIT OF SERVICE STATE OF NEW YORK, COUNTY OF __________________________ ss: _______________________________________________ being sworn says: I am over 18 years of age and on __________________, I served a true copy of this form and attachments in the following manner (check one): date Service by Mail By mailing the same in a sealed envelope, with postage prepaid thereon, in a post -office or official depository of the U.S. Postal Service within the State of New York, addressed to the last known address of the addressee(s) as indicated below: Personal Service By delivering the same personally to the persons and at the addresses indicated below: Sworn to before me on _____________________. ______________________________________________________________ Date Signature ________________________________________ _______________________________________________________________ Signer's Name (Please Print Notary Public MD -3 (1-11) Reverse www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com