Doctor's Report C-4.

3
of MMI/Permanent Impairment
Use this form: 1. When rendering an opinion on MMI and/or permanent impairment; or 2. In response to a request by the Workers'
Compensation Board to render a decision on MMI and/or permanent impairment.
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.

Date(s) of Examination:_______/_______/_______ WCB Case # (if known): Carrier Case #:

A. Patient's Information
1. Name: 2. Date of Birth: _____/_____/_____ 3. SSN: - -
Last First MI

4. Address (if changed from previous report) :

Number and Street City State Zip Code

5. Home phone #: (_____)_______________ 6. Date of injury/illness: _____/_____/_____ 7. Patient's Account #:

B. Doctor's Information
1. Your name: 2. WCB Authorization #:
First Last MI

3. WCB Rating Code: 4. Federal Tax ID #: The Tax ID # is the (check one): SSN EIN

5. Office address:
Number and Street City State Zip Code

6. Billing Group or Practice Name:

7. Billing address:
Number and Street City State Zip Code

8. Office phone #: (______)_____________ 9. Billing phone #: (______)______________ 10. Treating Provider's NPI #:

C. Billing Information
1. Employer's insurance carrier: 2. Carrier Code #: W
3. Insurance carrier's address:
Number and Street City State Zip Code
4. Diagnosis or nature of disease or injury:
Enter ICD10 Code: ICD10 Descriptor:
(1)
(2)
(3)
(4)
Relate ICD10 codes in (1), (2), (3) or (4) to Diagnosis Code column below by line.
Dates of Service Use WCB Codes
Place
From To Leave Procedures, Services or Supplies Days/ Zip code where service was
of Diagnosis Code $ Charges COB
Blank CPT/HCPCS MODIFIER Units rendered
MM DD YY MM DD YY Service

Total Charge Amount Paid Balance Due

Check here if services were provided by a WCB preferred provider organization (PPO). (Carrier Use Only) (Carrier Use Only)
$ $ $

C-4.3 (10-15) Page 1 THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES
PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.ny.gov
 Patient's Name: Date of injury/onset of illness:______/______/______
Last First MI

D. Maximum Medical Improvement

1. Has the patient reached Maximum Medical Improvement? Yes No If yes, provide the date patient reached MMI: _____/_____/_____
If No, describe why the patient has not reached MMI and the proposed treatment plan (attach additional documentation, if necessary).

E. Permanent Impairment/Work Status

1. Is there permanent impairment? Yes No
Complete either 1a. or 1b. based on the patient's current condition, if you believe there is MMI and a permanent impairment or if directed by the
Workers' Compensation Board.

If this is for Scheduled loss, please complete section 1a. below, sign Board Authorization at the bottom of this page, and return.
a. Schedule loss of use of member or facial disfigurement:
(Identify impairment rating according to the latest NY Guidelines and attach separate sheet for additional body parts.)
Body Part: Impairment %:
Body Part: Impairment %:
Body Part: Impairment %:

Describe findings and relevant diagnostic test results:

Facial Disfigurement: (Describe findings)

If this is for Non-Scheduled loss, please complete section 1b. below, complete page 3, Section F, sign Board Authorization at the bottom of page 3,
and return.
b. Non-Schedule losses:
(Identify impairment class according to the latest NY Guidelines. Attach separate sheet for additional body parts.)

Body Part: Impairment Table: Severity Ranking:

Body Part: Impairment Table: Severity Ranking:
Body Part: Impairment Table: Severity Ranking:
State the basis for the impairment classification (attach additional narrative, if necessary):
History:

Physical Findings:

Diagnostic Test Results:

2. Patient's work status:
a. Is the patient working now? Yes, at the pre-injury job Yes, at other employment No, Not Working
b. Could this patient perform his/her at-injury work activities without restrictions? Yes No
If this is a Scheduled loss (1a.), Section F should NOT be completed. Please sign Board Authorization below and return.
If this is a Non-Scheduled loss (1b), please complete page 3, Section F, sign Board Authorization at the bottom of page 3, and return.
This form is signed under penalty of perjury.
Board Authorized Health Care Provider signature:

/ /
Name Signature Specialty Date

C-4.3 (10-15) Page 2 THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES
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 Patient's Name: Date of injury/onset of illness:______/______/______
Last First MI

F. Functional Capabilities/Exertional Abilities

1. Please describe patient's residual functional capacities for any work at this time (not limited to the at-injury job activities):
Never Occasionally Frequently Constantly
Lifting/carrying lbs. lbs. lbs. Patient's Residual Functional Capacities
Pulling/pushing lbs. lbs. lbs. n Occasionally: can perform activity up to
1/3 of the time.
Sitting n Frequently: can perform activity from
Standing 1/3 to 2/3 of the time.
n Constantly: can perform activity more
Walking
than 2/3 of the time.
Climbing
Kneeling
Bending/stooping/squatting
Simple grasping
Fine manipulation
Reaching overhead
Reaching at/or below shoulder level
Driving a vehicle
Operating machinery
Temp extremes/high humidity
Environmental
Specify:
Psychiatric/neuro-behavioral (attach documentation describing functional limitations)
2. Please check the applicable category for the patient's exertional ability:
Very Heavy Work - Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force frequently, and/or in
excess of 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Heavy Work.
Heavy Work - Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force
constantly to move objects. Physical demand requirements are in excess of those for Medium Work.
Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up
to 10 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Light Work.
Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently and/or negligible amount of force
constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may
only be a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it
requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a
production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE:
The constant stress of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker
even though the amount of force exerted is negligible.
Sedentary Work - Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or
otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for
brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
Less than Sedentary Work - Unable to meet the requirement of Sedentary Work.
3. Other medical considerations which arise from this work related injury (including the use of pain medication such as narcotics):

4. Could this patient perform his/her at-injury work activities with restrictions? Yes No If Yes, specify

5. Has the patient had an injury/illness since the date of injury which impacts residual functional capacity?
Yes No If YES, please attach a detailed explanation.
6. Have you discussed the patient's return to work and/or limitations with any of the following: patient patient's employer N/A
7. Would the patient benefit from vocational rehabilitation? Yes No If Yes, explain

This form is signed under penalty of perjury.

Board Authorized Health Care Provider signature:
/ /
Name Signature Specialty Date

C-4.3 (10-15) Page 3 THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES
PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION www.wcb.ny.gov
 IMPORTANT - TO THE ATTENDING DOCTOR
The C-4.3 has been modified to accommodate the 2012 Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity. This form
is to be used to file reports in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefits cases as follows: 1. When rendering
an opinion on MMI and/or permanent impairment; or 2. In response to a request by the Workers' Compensation Board to render a decision on MMI and/or
permanent impairment.
MEDICAL REPORTING
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 attending doctor and must contain his/her authorization certificate number, code letters and NPI number.
A CHIROPRACTOR OR PODIATRIST FILING THIS REPORT CERTIFIES THAT THE INJURY DESCRIBED CONSISTS SOLELY OF A CONDITION(S) WHICH MAY LAWFULLY BE
TREATED AS DEFINED IN THE EDUCATION LAW AND, WHERE IT DOES NOT, HAS ADVISED THE INJURED PERSON TO CONSULT A PHYSICIAN OF HIS/HER CHOICE.
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.
Instructions for Completing Section D, E and F
Section D. Maximum Medical Improvement
Section D includes questions regarding maximum medical improvement (MMI). For the definition of MMI, see Chapter 1.2 of the 2012 Guidelines. A provider who finds that
the patient has met MMI should so indicate and provide the approximate date of such finding (Question 1). A provider who determines that the patient has not yet reached
MMI should so indicate (Question 1) and provide an explanation as to why additional improvement is expected and the proposed treatment plan.

Section E. Permanent Impairment/Work Status

Section E includes questions regarding permanent impairment/work status. A provider who finds that there is no permanent impairment (Question 1) should not file this form
and use Form C-4.2 (Dr's. Progress Report). For more information on evaluating impairment, see Chapter 9.2 of the 2012 Guidelines.
A provider should complete either 1a. (Schedule loss of use of member or facial disfigurement) or 1b. (Non-Schedule losses). A provider should complete Question 2
pertaining to the patient's work status.
1a. Schedule loss of use of member or facial disfigurement. A provider should determine impairment % using the impairment guidelines in Chapters 2-8. If this is a
Scheduled loss, Section F., Functional Capabilities/Exertional Abilities, should not be completed. A provider should sign the Board Authorization at the bottom of page 2 and
return to the Workers' Compensation Board.
1b. Non-Schedule loss. If this is a Non-schedule loss, a provider should record the body part, impairment table and severity letter grade for each body part or system. A
provider should also state the history, physical findings, and diagnostic test results that support the impairment finding. If the patient has a non-schedule impairment of a
body part or system that is not covered by an impairment guideline, the provider should follow Chapter 17 and include the relevant history, physical findings, and diagnostic
test results, but no severity letter grade.
In addition, if this is a Non-schedule loss, a provider should complete Section F, Functional Capabilities/Exertional Abilities. A provider should complete Section F based on
the patient's current condition if they believe there is MMI and/or permanent impairment or in a response to a request by the Board to render a decision on MMI and/or
permanent impairment.

Section F. Functional Capabilities/Exertional Abilities

Section F includes questions applicable to a patient who has reached MMI and has a permanent, non-schedule impairment. For more information on evaluating functional
capabilities, see Chapter 9.2 of the 2012 Guidelines. A provider should measure and record the specific functional abilities and losses caused by the work-related medical
impairment on Questions 1 through 5 as follows:
Question 1 - The provider should rate whether the patient can perform each of the fifteen functional abilities never, occasionally, frequently, or constantly. The provider
should note the specific weight tolerances for the categories lifting/carrying and pulling/pushing. There is also room to describe any functional limitations in connection with
environmental conditions (e.g., occupational asthma). Attach documentation when describing Psychiatric/neuro-behaviorial functional limitations, if applicable to a patient.
Question 2 - The provider should rate the patient's exertional ability according to the federal standards set forth by the Department of Labor.
Question 3 - The provider should note any other medical considerations arising from the permanent injury that are not captured elsewhere in Sections E and F. This includes
any restrictions or limitations that may be imposed as a result of medications (e.g., narcotics) taken by the patient or other relevant medical considerations that impact work
function.
Question 4 - If Yes, the provider should specifically assess the patient's ability to perform his/her at-injury work activities with restrictions.
Question 5 - If Yes, the provider should attach a detailed explanation if the patient has had an intervening injury or illness that may account for any of the functional
restrictions noted in Question 1.

BILLING INFORMATION
Complete all billing information contained on this form. Use continuation Form C-4.1, if necessary. A physician who fully completes an evaluation of permanent
impairment, including a full evaluation of functional limitations, on a Form C-4.3 shall be entitled to payment for a Level 5 E&M consultation code (CPT99245).
The workers' compensation carrier has 45 days to pay your bill or to file an objection to it. Contact the workers' compensation carrier if you receive neither
payment nor an objection within this time period. After contacting the carrier, you may, if necessary, contact the Board's Disputed Bill Unit at 866-750-5157 for
information/assistance.
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-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT
TO SUBSTANTIAL FINES AND IMPRISONMENT.

All reports are to be filed by sending directly to the Workers' Compensation Board at the address below with a copy sent to the
insurance carrier:
Statewide Fax Line: 877-533-0337
OR
NYS Workers' Compensation Board - Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205
C-4.3 (10-15) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION