Continuation To Carrier-Employer Billing Portion Of Forms C-4 C-4.2 C-4.3 C-5 PS-4 Or OT-PT-4
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Continuation To Carrier-Employer Billing Portion Of Forms C-4 C-4.2 C-4.3 C-5 PS-4 Or OT-PT-4 Form. This is a New York form and can be use in Workers Compensation.
Tags: Continuation To Carrier-Employer Billing Portion Of Forms C-4 C-4.2 C-4.3 C-5 PS-4 Or OT-PT-4, C-4.1, New York Workers Compensation,
CONTINUATION TO CARRIER/EMPLOYER BILLING PORTION
OF FORMS C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4
Doctor's Name
Carrier Case Number
WCB Case Number
Patient
A
MM
B
Dates of Service
From
DD
YY
MM
To
DD
YY
C
Place Leave
of
Blank
Service
Date of Accident or Injury
Patient's Social Security Number:
D
(USE WCB CODE)
Procedures, Services or Supplies
CPT/HCPCS
MODIFIER
E
Diagnosis Code
F
G
H
$ Charges
Days or
Units
COB
I
Zip Code Where Service was
Rendered
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19..
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
C-4.1 (9-08)
THE INJURED WORKER SHOULD NOT PAY THIS BILL.
NY-WCB
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