Doctor's Initial Report Use this form to report the first time you treated the patient. (To report continued treatment, use Form C-4.2. To report permanent impairment, use Form C-4.3.) C-4 Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.wcb.ny.gov. A. Patient's Information 1. Name: Last First MI 2. Social Security #: 5. Carrier Case #: City State - - 3. Home phone #: (_____)_______________ 4. WCB Case # (if known): 6. Mailing address: Number and Street Zip Code 7. Date of injury/onset of illness: ______/______/______ 8. Date of Birth: ______/______/______ 10. On the date of injury/illness what was the patient's job title or description: 9. Gender: Male Female 11. On the date of injury/illness what were the patient's usual work activities:_______________________________________________________ 12. Patient's Account #: B. Employer Information 1. Employer when injury occurred: 3. Employer Address: Company/Agency Name Number and Street City 2. Phone #: (______)_______________ State Zip Code C. Doctor's Information 1. Your name: Last First MI 2. WCB Authorization #: 4. Federal Tax ID #: Number and Street City 3. WCB Rating Code: 5. Office address: 6. Billing group or practice name: 7. Billing address: The Tax ID # is the (check one): State SSN Zip Code EIN Number and Street City State Zip Code 8. Office phone #: (______)_____________ 9. Billing phone #: (______)______________ 10. Treating Provider's NPI #: 11. You are a (check one): Physician Podiatrist Chiropractor D. Billing Information 1. Employer's insurance carrier: 3. Insurance carrier's address: 4. Diagnosis or nature of disease or injury: Enter ICD10 Code: (1) (2) (3) (4) Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column on page 2 by line. C-4.0 (10-15) Page 1 of 4 THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION Number and Street City 2. Carrier Code #: W State Zip Code ICD10 Descriptor: American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.ny.gov Patient's Name: Last Dates of Service From MM To DD YY MM DD YY Place Leave of Service Blank First MI Date of injury/onset of illness:______/______/______ Diagnosis Code $ Charges Days/ Units COB Zip code where service was rendered Use WCB Codes Procedures, Services or Supplies CPT/HCPCS MODIFIER Total Charge Check here if services were provided by a WCB preferred provider organization (PPO). Amount Paid (Carrier Use Only) Balance Due (Carrier Use Only) $ $ $ E. History 1. Based on the patient's history, where and how did the injury/illness happen: 2. How did you learn about the injury/illness (check one): Patient Medical Records Other(specify): Yes No No If yes, give details: 3. Did another health provider treat this injury/illness including hospitalizaton and/or surgery? 4. Have you previously treated this patient for a similar work-related injury/illness? Yes If yes, when: ________________________ F. Exam Information 1. Date(s) of Examination: 2. Patient's subjective complaints: Check all that apply and identify specific affected body part(s). Numbness/Tingling Pain Stiffness Swelling Weakness Other (specify) 3. Type/nature of injury: Check all that apply and identify specific affected body part(s). Abrasion Amputation Avulsion Bite Burn Contusion/Hematoma Crush Injury Dermatitis Dislocation Fracture Hearing Loss Hernia Other (specify) Infectious Disease Inhalation Exposure Laceration Needle Stick Poisoning/Toxic Effects Psychological Puncture Wound Repetitive Strain Injury Spinal Cord Injury Sprain/Strain Torn Ligament,Tendon or Muscle Vision Loss C-4.0 (10-15) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.ny.gov Patient's Name: Last First MI Date of injury/onset of illness:______/______/______ 4. Physical examination: Check all relevant objective findings and identify specific affected body part(s). None at present Neuromuscular Findings: Bruising Abnormal/Restricted ROM Burns Active ROM Crepitation Passive ROM Deformity Gait Edema Palpable Muscle Spasm Hematoma/Lump/Swelling Reflexes Joint Effusion Sensation Laceration/Sutures Pain/Tenderness Scar Strength (Weakness) Wasting/Muscle Atrophy Other findings:___________________________________________________________________________________________________ 5. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________ 6. Describe any treatment(s) rendered at this visit: ___________________________________________________________________________ 7. Describe prognosis for recovery: _______________________________________________________________________________________ 8. Does the patient's medical history reveal any pre-existing condition(s) that may affect the treatment and/or prognosis? If yes, list and describe: Yes No G. Doctor's Opinion 1. In your opinion, was the incident that the patient described the competent medical cause of this injury/illness? 2. Are the patient's complaints consistent with his/her history of the injury/illness? 3. Is the patient's history of the injury/illness consistent with your objective findings? 4. What is the percentage (0-100%) of temporary impairment? _________% 5. Describe findings and relevant diagnostic test results:______________________________________________________________________ ________________________________________________________________________________________________________________ Yes Yes No No N/A (no findings at this time) Yes No H. Plan of Care 1. What is your proposed treatment? 2. Medication(s):(a) list medications prescribed: _____________________________________________________________________________ (b) list over-the-counter medications advised:__________________________________________________________________ Medication restrictions: None May affect patient's ability to return to work, make patient drowsy, or other issue. Explain below: C-4.0 (10-15) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.ny.gov Patient's Name: Last First MI Date of in