Since New York retired its C-4 family of medical report forms in July 2022, every CMS-1500 bill in a workers' compensation case must travel with a medical narrative. This one-page Board template captures the three elements a report needs to avoid being found legally defective: work status, causal relationship and temporary impairment percentage. The provider attaches the full examination narrative and sends both with the bill.
The Board-authorized provider who signs field 31 of the CMS-1500 completes and signs the whole template, adds the WCB authorization number, rating code and NPI, and attaches the narrative. Physician assistants, physical and occupational therapists and acupuncturists have limits on what they may state, and the patient completes nothing.
Enter the patient's name and date of birth, the WCB case number if known, the insurer's case number, and the date of injury or onset of illness. These identifiers tie the narrative to the claim and to the CMS-1500 it accompanies, so they should match what is on the bill submitted through the submission partner.
Identify the treating provider by name, NPI, WCB authorization number and WCB rating code, and list the date or dates of service the report covers. The instructions require the template to be signed by the provider who signs field 31 of the CMS-1500 and to carry that provider's authorization number, rating code and NPI.
State whether the patient missed work because of the injury or illness and the first date missed, and whether the patient is working, with the date limited or full duty resumed. If the patient is not working, say whether they can return to usual work activities and describe and quantify any limitations, including how long they are expected to last. Physical and occupational therapists and acupuncturists may not answer the return-to-work and limitation questions.
Answer whether the incident the patient described is the competent medical cause of the injury or illness, whether the complaints are consistent with the patient's history, and whether that history is consistent with the objective findings or not applicable at this visit. A record, report or opinion of a physical or occupational therapist, acupuncturist or physician assistant is not considered evidence of causal relationship.
Give a percentage from 0 to 100 and describe the findings and how the percentage was determined. Physical and occupational therapists and acupuncturists may not provide a percentage, and a physician assistant's record, report or opinion may not be considered evidence of an initial disability or its degree.
Attach the narrative report to the template. It should cover the history of the injury or illness, objective findings from the clinical evaluation, the plan of care, and the diagnoses or assessment. The Board's sample initial report adds detail such as affected body parts, prior treatment, current medications with doses, tests, referrals and follow-up, and asks for diagnoses stated in words rather than billing codes alone.
The provider signs and dates the template. Because it travels with the bill, the signer must be the same provider who signs field 31 of the CMS-1500. The form warns that knowingly presenting false material statements to an insurer or self-insurer, or concealing a material fact, is a crime subject to substantial fines and imprisonment.
Download the current version from the source each time; forms change without notice.
Medical Narrative Report Template for CMS-1500
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Sources for this guide
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No. The template is optional, but a narrative is not. Every CMS-1500 submission needs a medical narrative, and the Board accepts the provider's own report in place of the template as long as it includes work status, causal relationship and temporary impairment percentage. The narrative with examination findings must be attached either way.
The provider who signs field 31 of the CMS-1500 signs the template and lists their WCB authorization number, rating code and NPI. Physicians, chiropractors, nurse practitioners, podiatrists, psychologists and social workers can address all three elements. Opinions from physician assistants, physical and occupational therapists and acupuncturists are not evidence of causal relationship.
The initial report is due within 48 hours after first treatment. A progress report follows within 15 days of the initial report, and during continued treatment a report is filed for each medically necessary follow-up visit, with no more than 90 days between reports.
In July 2022 the Board replaced 12 custom medical forms, including the C-4, C-4.2, C-4AMR, C-5, EC-4NARR, PS-4 and PT-4/OT-4, with the CMS-1500 plus a medical narrative. Crosswalk PDFs on the Board's CMS-1500 requirements page map each retired form's content to the new format.