The narrative report that goes with every CMS-1500, the OnBoard prior authorization requests, the C-4.3 impairment report and the IME and impartial specialist forms.
New York's Workers' Compensation Board retired most of its C-4 medical report forms on July 1, 2022. A treating provider now bills on the CMS-1500 with a medical narrative stating work status, causal relationship and temporary impairment percentage, and the Board's Medical Narrative Report Template is one way to write it. Medications, Medical Treatment Guidelines (MTG) variances, durable medical equipment and other prior authorizations are requested online in OnBoard. The Doctor's Report of MMI/Permanent Partial Impairment (C-4.3) is still a form.
Bills go electronically through a Board-approved submission partner, mandatory since August 1, 2025, with the initial report within 48 hours and the next within 15 days. The template is optional if your own narrative covers the three required elements. Delegates may draft a prior authorization request, but only the treating provider submits it, and paper requests are not accepted. Independent medical examiners file the IME-4 cover sheet with the IME-4.3A and IME-4.3B attachments.
Medical report that must accompany every CMS-1500 bill, stating work status, causal relationship and temporary impairment percentage, with the narrative of exam findings attached.
Requests approval of a medication not on the NY Workers' Compensation Drug Formulary (including medical marijuana) or otherwise needing prior authorization.
Requests approval of treatment or testing that varies from the NY Medical Treatment Guidelines.
Requests approval of durable medical equipment under the Official NY Workers' Compensation DME Fee Schedule.
Optional request to confirm that treatment consistent with the Medical Treatment Guidelines will be paid.
Requests authorization for special services addressed by the Medical Treatment Guidelines (e.g. surgery-level services) that require prior approval.
Requests authorization for treatment of body parts/conditions not covered by the Medical Treatment Guidelines costing over $1,000.
Treating provider's opinion on maximum medical improvement, schedule loss of use and non-schedule permanent impairment, and functional capabilities, using the 2018 and 2012 impairment guidelines.
Cover sheet and certification for the narrative report of an independent medical examination requested by the carrier/employer or claimant.
IME findings on permanent partial disability of scheduled body parts (schedule loss of use).
Requests authorization for non-MTG treatment costing $1,000 or less.
Physician's certification of the cause of death and whether the work accident or injury caused or contributed to it, for death benefit claims.
Reports the results of a functional capacity evaluation requested by the carrier/employer or attending physician after maximum medical improvement.
Independent examiner's report, required by WCL Section 137, of any request for information received about an IME and of the response given.
IME-4.3BIME findings on non-schedule permanent partial disability (impairment classification and severity) and functional capacity.
Report of a Board-designated impartial specialist's examination or record review.
Impartial specialist's records review, requested by the Board, of a treatment or procedure that needs pre-authorization under the Medical Treatment Guidelines.
Records audiometric test results and calculates percentage hearing loss for occupational loss of hearing claims under WCL Section 49-gg.
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The CMS-1500 plus a medical narrative report. On July 1, 2022, the Board replaced the C-4, C-4.1, C-4.2, C-4AMR, C-5, EC-4NARR, PS-4 and OT/PT-4 with that pair. The narrative must state work status, causal relationship and temporary impairment percentage, with exam findings attached. The Board's Medical Narrative Report Template covers those elements, but your own narrative is accepted if it does too. The C-4.3 was not retired.
Online in OnBoard, through the Board's Medical Portal, after a claim search. Request types cover medications (including medical marijuana), durable medical equipment, MTG variances, MTG confirmation, MTG special services and non-MTG treatment. Delegates may draft a request, but only the treating provider submits it, and paper requests are not accepted. The claim administrator answers medication and DME requests in OnBoard within 4 calendar days.
Attach it to the electronically submitted CMS-1500 as the medical narrative rather than sending it to the Board separately, and send copies to the carrier and to the claimant's representative or the claimant. It records maximum medical improvement, schedule loss of use, non-schedule permanent impairment and functional capabilities under the 2018 and 2012 impairment guidelines. The C-4.3 is an XFA form, so fill it in Adobe Acrobat or Reader.
The Board, the carrier or self-insured employer, the attending physician, the claimant's representative and the claimant, all on the same day and in the same manner. The IME-4 is the cover sheet and certification for the independent medical examination narrative, and its certification wording is mandatory. Schedule loss of use findings go on the IME-4.3A, and non-schedule permanent partial disability on the IME-4.3B.