STATE OF NEW YORK - WORKERS' COMPENSATION BOARD IMPARTIAL SPECIALIST'S REPORT OF MEDICAL RECORDS REVIEW THIS RECORD REVIEW WAS REQUESTED BY THE WORKERS' COMPENSATION BOARD. This form should only be used for procedures that require pre-authorization under the Medical Treatment Guidelines. WCB CASE NO. CARRIER CASE NO. (IF KNOWN) DATE OF INJURY INJURED PERSON'S SOCIAL SECURITY NUMBER ADDRESS (Include Apt. No.) MR-4 DATE OF REVIEW INJURED PERSON EMPLOYER INSURANCE CARRIER (First Name) (Middle Initial) (Last Name) Treatment/Procedure Requested:____________________________________________________________________________ Results of Records Review (continue on reverse or attach additional sheets, if necessary) I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's condition. ________________________________________________ Impartial Specialist's Name ____________________________ Date Impartial Specialist's Signature Impartial Specialist's Address MR-4 (1-11) American LegalNet, Inc. www.FormsWorkFlow.com It is unlawful for any person who has obtained individually identifiable information from Workers' Compensation Board records to disclose such information to any person who is not otherwise lawfully entitled to obtain these records. Any person who knowingly and willfully obtains workers' compensation records which contain individually identifiable information under false pretenses or otherwise violates Workers' Compensation Law Section 110-a shall be guilty of a class A misdemeanor and shall be subject upon conviction, to a fine of not more than one thousand dollars. HIPAA Notice: In order to adjudicate a workers' compensation claim, WCL Sections 13(e) permits the Board to have a claimant and/or his/her medical records examined by a designated health care provider. Pursuant to 45 CFR 164.512(l), a health care provider who has been retained by the Board to evaluate a workplace injury is exempt from HIPAA's restrictions on disclosure of health information. NYS WORKERS' COMPENSATION BOARD NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205 Customer Service Toll-Free Line: 877-632-4996 Statewide Fax Line: 877-533-0337 Address for Email Filing: wcbclaimsfiling@wcb.ny.gov THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION MR-4 Reverse (1-11) www.wcb.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com