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NY WCB MR-4: Impartial Specialist Records Review

When the New York Workers' Compensation Board needs an independent opinion on a requested treatment or procedure that requires pre-authorization under the Medical Treatment Guidelines, it can ask an impartial specialist to review the records. The specialist reports on the two-page MR-4, naming the treatment or procedure requested and giving the results of the records review, continued on the reverse or on attached sheets.

Who completes it

The Board-designated impartial specialist completes the whole form, certifies that it is a full and truthful representation of their professional opinion, and signs with name, address and date.

Submitting and payment

How to submit it
Return the completed report to the Workers' Compensation Board by mail to its centralized mailing address or through its email filing option.

Good to know

  • The form states it should only be used for procedures that require pre-authorization under the Medical Treatment Guidelines.
  • Since 2022, treating providers request MTG pre-authorization through OnBoard prior authorization requests, though the MR-4 remains on the Board's forms list.
  • Under WCL Section 13(e), the Board may have a claimant's medical records examined by a designated provider, who is exempt from HIPAA's disclosure restrictions for that review.
  • Disclosing identifiable information from Board records to anyone not entitled to it is unlawful under WCL Section 110-a.

Get the official form

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

Impartial Specialist's Report of Medical Records Review

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

Who requests an MR-4 records review?

The Workers' Compensation Board. The form states the record review was requested by the Board and that it applies only to procedures requiring pre-authorization under the Medical Treatment Guidelines. The impartial specialist reviews the records and reports the results without examining the claimant.

How is the MR-4 different from the IS-4?

The IS-4 reports an impartial specialist's examination or records review on a complex medical issue raised by a Board panel, a Law Judge or the parties. The MR-4 is a records-only review focused on a specific treatment or procedure that needs pre-authorization under the Medical Treatment Guidelines.

What does the impartial specialist certify on the MR-4?

That the report is a full and truthful representation of the specialist's professional opinion with respect to the claimant's condition. The certification is followed by the impartial specialist's printed name, signature, date and address, and the report identifies the injured person, employer, carrier and WCB case number.