OCCUPATIONAL THERAPIST'S REPORT PHYSICAL THERAPIST'S REPORT 48 HR. INITIAL STATE OF NEW YORK WORKERS' COMPENSATION BOARD SERVICES PROVIDED UNDER WCB PREFERRED PROVIDER ORGANIZATION (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 TELEPHONE NO. WCB CASE NO. CARRIER CASE NO. (IF KNOWN) INJURED PERSON EMPLOYER* INSURANCE CARRIER (First Name) (Middle Initial) (Last Name) ADDRESS (Include Apt. No.) PATIENT'S DATE OF BIRTH REFERRING PHYSICIAN/ PODIATRIST TELEPHONE NO. *If treatment was under the VFBL or VAWBL show as "Employer" the liable political subdivision and check one: If you have filed a previous report, setting forth a history of the injury, enter its date 1. Diagnosis of referring physician/podiatrist. VFBL VAWBL and complete Items 3 to 16. If not, complete ALL items. H I S T 2. If patient has given any history of pre-existing injury, disease or physical impairment, describe specifically. O R Y 3. Referral was for: Evaluation Only (Complete item a) a. Your evaluation: Treatment Only (Complete item b-1,2,3) Evaluation and Treatment (Complete items a and b-1,2,3) E V A L U A b. (1) Patient's condition and progress: T I O N / b. (2) Treatment and planned future treatment. If an authorization request is required (see items 4 & 5 on reverse), check box and explain below. If additional space is necessary, please attach request. T R E A T b. (3) Was such treatment plan upon prescription or referral of claimant's attending physician or, in the case of physical therapy, authorized physician or podiatrist? M Yes No If yes, frequency of treatment ordered: Period of treatment ordered: E 4. Date(s) of visits on which this report is based Date of First Visit Will patient be seen again? Yes No If yes, when: N If no, was patient referred back to attending doctor: Yes No T 5. Is patient working? Yes No If yes, date(s) patient: resumed limited work of any kind resumed regular work 6. Diagnosis or nature of disease or injury (Relate Items 1,2,3 or 4 to Item 7E by line.) Enter ICD10 code and describe nature of injury. 1. 3. 2. 4. B 7. A I Dates of Service L From To MM YY MM DD DD L I N G B YY C D (USE WCB CODES) E Diagnosis Code F $ Charges G Days or Units H COB I Zip Code Where Service was Rendered Place Leave of Service Blank Procedures, Services or Supplies (Explain Unusual Circumstances) CPT/HCPCS MODIFIER F O R M S I G N A T U R E 8. Federal Tax I.D. Number SSN EIN 9. NYS License Number 10. Patient's Account Number 11. Total Charges 12. Amt. Paid (carrier use only) 13. Bal. Due (carrier use only) Affirmed Under Penalty of Perjury 15. Therapist's Name, Address & Phone No. 16. Therapist's Billing Name, Address & Phone No. 14. Signature of Treating Therapist Date THE INJURED WORKER SHOULD NOT PAY THIS BILL www.wcb.ny.gov OT/PT-4 (10-15) SEE REVERSE SIDE FOR IMPORTANT INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com IMPORTANT TO THE OCCUPATIONAL/PHYSICAL THERAPIST 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 at intervals of 90 days during continuing treatment, unless change of condition necessitates additional reporting. 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. A copy must also be filed with the prescribing or referring physician or podiatrist. 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. This form must be signed by the occupational/physical therapist and must contain his/her authorization number, address and telephone number. AUTHORIZATION FOR SPECIAL SERVICES - Prior authorization for occupational/physical therapy procedures costing more than $1,000 or procedures requiring preauthorization pursuant to the Medical Treatment Guidelines for the back, neck, knee and shoulder must be requested from the self-insured employer or insurance carrier. 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 3 b(2) of this form. Attach copy of request, if necessary. c. The self-insured employer or insurance carrier may have the patient examined within 4 working days of the request for authorization, if the patient is hospitalized, or within 30 calendar days if the patient is not hospitalized. d. If authorization or denial is not forthcoming within 30 calendar days, notify the nearest office of the Workers' Compensation Board. LIMITATION OF OCCUPATIONAL/PHYSICAL THERAPY TREATMENT - Treatment by a licensed occupational/physical therapist is limited as defined in Article 136 or 156 of the Education Law, in the Workers' Compensation Law, and the Rules of the Chair relative to Occupational/Physical Therapy Practice. 2. 3. 4. 5. 6. 7. HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF