Nevada's C-4 starts a workers' compensation claim and documents the first treatment on one page. The injured employee completes the claim on the top half at the first visit. The treating provider completes the Report of Initial Treatment below: diagnosis, treatment, X-ray findings, signs of intoxication, whether the patient should stay off work five days or more, full or modified duty, and whether the condition is job incurred.
The employee completes and signs the top half, which includes a medical release authorization. A treating physician, chiropractic physician, PA-C or APRN completes and signs the Report of Initial Treatment, giving degree, tax ID and the date the employer's copy was delivered.
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Employee's Claim for Compensation/Report of Initial Treatment
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The form states the report must be completed and mailed within 3 working days of treatment. The four-part form keeps the original with the treating provider, with copies for the insurer or third-party administrator, the employer and the employee, and the provider certifies the date the employer's copy was delivered.
The degree box lists MD, DO, DC, PA-C and APRN, so a physician, chiropractic physician, certified physician assistant or advanced practice registered nurse providing the initial treatment can sign. An original or electronic signature is accepted, along with the provider's tax ID number and address.
Generally not. The employee section includes an authorization to share medical information about the injury, except records about AIDS, psychological conditions, or alcohol or controlled substances, which need specific authorization. The separate C-4A release was discontinued effective 9/13/23.