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NY C-4.3: Doctor's Report of MMI/Permanent Impairment

New York treating providers file the C-4.3 when they give an opinion on maximum medical improvement or permanent partial impairment, or when the Workers' Compensation Board asks for one. Attachment A rates schedule loss of use under the 2018 Impairment Guidelines, and Attachment B classifies non-schedule impairment under the 2012 Guidelines, with work status, functional capacities, exertional level and vocational questions.

Who completes it

The Board-authorized treating provider completes it and signs under penalty of perjury, with authorization number, rating code and NPI. Chiropractors, podiatrists, psychologists, nurse practitioners and licensed clinical social workers may file within their scope of practice.

Submitting and payment

How to submit it
Attach the C-4.3 to the electronically submitted CMS-1500 as the medical narrative instead of sending it separately to the Board. Send copies to the carrier and the patient's attorney or licensed representative, or to the patient if unrepresented.
Who pays
The carrier has 45 days to pay the CMS-1500 bill or file an objection, and if neither arrives after contacting the carrier, the provider can file Form HP-1 for a decision on the unpaid bill.

Good to know

  • If there is no permanent partial impairment, do not file a C-4.3; use the C-4.2 progress report instead unless the Board has asked for an MMI or impairment opinion.
  • For schedule loss of use, take three active range-of-motion measurements, use the greatest, measure the contralateral side, and apportion any prior schedule awards to the same body part.
  • Occupational hearing loss goes on Form C-72.1; traumatic hearing loss, vision loss (or Form C-5) and serious facial disfigurement use the C-4.3 with a narrative.
  • The form is an XFA PDF, so fill it in Adobe Acrobat or Reader, and submit only the pages that apply to the report.

Get the official form

Download the current version from the source each time; forms change without notice.

Doctor's Report of MMI/Permanent Partial Impairment

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Which impairment guidelines does the NY C-4.3 use?

Both editions. Schedule loss of use in Attachment A is determined with the 2018 Workers' Compensation Guidelines for Determining Impairment. Non-schedule permanent impairments in Attachment B are classified with the 2012 Guidelines, recording body part, impairment table and severity ranking, with Chapter 17 used where no impairment guideline applies.

Do I send the C-4.3 directly to the Board?

No. The form says to submit it attached to the electronically submitted CMS-1500 medical bill as the medical narrative and not to send it separately to the Board. Copies go to the insurance carrier and to the patient's attorney or licensed representative, or to the patient if there is none.

Can a nurse practitioner or chiropractor file a C-4.3?

Yes, within scope. A chiropractor, podiatrist, psychologist, nurse practitioner or licensed clinical social worker filing the report certifies that the injury consists solely of conditions they may lawfully treat or, where it does not, that they advised the patient to consult a physician of the patient's choice.