Fill in a Valid C 4 3 Template

The C 4 3 form, known as the Doctor's Report C-4.3 of Maximum Medical Improvement (MMI) and Permanent Partial Impairment, is essential for evaluating a patient's medical status in relation to workers' compensation cases. This form is utilized when providing an opinion on MMI or responding to requests from the Workers' Compensation Board for decisions regarding partial impairments. Ensure to complete the form accurately and submit it promptly to avoid delays in treatment or benefits.

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The C 4 3 form, known formally as the Doctor's Report C-4.3 of Maximum Medical Improvement (MMI) and Permanent Partial Impairment, plays a crucial role in the workers' compensation process. It is utilized primarily by healthcare providers to offer their expert opinions on whether a patient has reached MMI or suffers from a permanent partial impairment due to a work-related injury. This comprehensive document is not only a tool for assessment but also a necessary step when responding to requests from the Workers' Compensation Board. Completing the form accurately is essential; it includes fields for patient information, doctor's details, and billing specifics. Each section requires thorough responses, as any omissions could delay treatment payments or wage loss benefits for the injured individual. Healthcare providers must include a detailed narrative, particularly when claiming a permanent partial impairment, and must consider factors like the patient's range of motion and functional capabilities. Completing the form online is also an option, facilitating quicker submissions. In short, the C 4 3 form is vital for ensuring that the workers' compensation process proceeds smoothly, safeguarding both healthcare providers’ authority and patients’ rights.

C 4 3 Example

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

Use this form: 1. When rendering an opinion on MMI and/or permanent partial impairment; or 2. In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent partial impairment.

Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the patient, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.wcb.ny.gov.

Date(s) of Examination:_______/_______/_______ WCB Case #:Claim Admin Claim Number:

A. Patient's Information

1. Name:				2. Date of Birth: _____/_____/_____ 3. SSN:			-	-
	Last	First	MI
4. Address (if changed from previous report) :
			Number and Street		City	State		Zip Code
5. Home phone #: (_____)_______________ 6. Date of injury/illness: _____/_____/_____					7. Patient's Account #:

B. Doctor's Information

1. Your name:

2. WCB Authorization #:

First

Last

WCB Rating Code:

4. Federal Tax ID #:

The Tax ID # is the (check one):

SSN

EIN

Office address:

Number and Street

City

State

Zip Code

Billing Group or Practice Name:

Billing address:

Number and Street

City

State

Zip Code

Office phone #: (______)_____________ 9. Billing phone #: (______)______________

10. Treating Provider's NPI #:

C. Billing Information

Employer's insurance carrier:

2. Carrier Code #: W

Insurance carrier's address:

Number and Street

City

State

Zip Code

4. Date of Exam:

5. Billing (CPT) Code:

Charge ($):

7. Zip Code:

C-4.3 (11-21) Page 1

C-4.3 11-21

Patient's Name:

Last

First

Date of injury/onset of illness:______/______/______

D. Maximum Medical Improvement

1. Has the patient reached Maximum Medical Improvement? Yes No If yes, provide the date patient reached MMI: _____/_____/_____

If No, describe why the patient has not reached MMI and the proposed treatment plan (attach additional documentation, if necessary).

E. Permanent Partial Impairment

1.Is there permanent partial impairment? Yes No

2.List the body parts and conditions you treated the patient for related to the date of injury listed in Section A, Question 6.

Complete Permanent Partial Disability, Attachment A and/or Attachment B, as indicated based on the patient's condition. Attachment A and/or Attachment B must be completed for each body part and/or condition which you treated the patient for on the date of injury listed in Section A, Question 6.

nFor a permanent partial impairment where schedule award (schedule loss of use) is appropriate, complete Attachment A, except for serious facial disfigurement, vision, or hearing loss.

Hearing Loss:

lOccupational Loss of Hearing - C-72.1 should be utilized, and/or

lTraumatic Hearing Loss - C4.3 with an attached narrative.

Vision Loss:

lAttending Ophthalmologist's Report (Form C-5), or

lC-4.3 with an attached narrative.

Serious Facial Disfigurement

lC-4.3 with an attached narrative.

nFor a non-schedule award (classification), complete Attachment B.

Sign below and submit to the Board only the pages of the form that apply to this report.

This form is signed under penalty of perjury.

Board Authorized Health Care Provider signature:

		/	/
Name	Signature	Specialty	Date
C-4.3 (11-21) Page 2		C-4.3 11-21

Patient's Name:				Date of injury/onset of illness:______/______/______
	Last	First	MI

Permanent Partial Disability - Attachment A

Schedule Loss of Use of Member

If the patient has a permanent partial impairment, complete Attachment A for all body parts and conditions for which a schedule award is appropriate (schedule loss of use). You must complete this attachment for all body parts and conditions for which you treated the patient for the date of injury listed in Section A, Question 6. Attach additional sheets if needed.

Body Part

Please include all the information in the bullet points below in the table on this page or attach a medical narrative with your report. The medical narrative should include the following information:

lAffected body part (include left or right side) and identify Guideline chapter (when special consideration exist).

lMeasured Active Range of Motion (ROM) (3 measurements for injured body part, and use the greatest ROM). If not, please explain why.

lMeasurement of contralateral body part ROM, or explain why inapplicable

lPreviously received scheduled losses of use to same body part(s), if known

lSpecial considerations

lLoading for Digits and Toes

C-4.3 11-21

Body Part/Measurement

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

Left

Right

Range of Motion

(3 measures)

Contralateral

Applicable Y/N

If No, please

explain below

Contralateral ROM

Special Considerations

(Chapter)

Impairment %

Details:

C-4.3A (11-21) Page 3

Patient's Name:

Last

First

Date of injury/onset of illness:______/______/______

Permanent Partial Disability - Attachment B

Non-Schedule Award (Classification)

1. Non-Schedule Permanent Partial Disability:

(Identify impairment class according to the latest Workers' Compensation Guidelines for Determining Impairment. Attach separate sheet for
additional body parts.)
Body Part:	Impairment Table:	Severity Ranking:
Body Part:	Impairment Table:	Severity Ranking:
Body Part:	Impairment Table:	Severity Ranking:

State the basis for the impairment classification (attach additional narrative, if necessary):

History:

Physical Findings:

Diagnostic Test Results:

2. Patient's Work Status:

At the pre-injury job

At other employment

Not working

3.Functional Capabilities/Exertion Abilities:

a. Please describe patient's residual functional capacities for any work at this time (not limited to the at-injury job activities):

Never

Occasionally

Frequently

Constantly

Lifting/carrying

lbs.

Pulling/pushing

lbs.

Sitting

Patient's Residual Functional Capacities

Standing

n Occasionally: can perform activity up to

1/3 of the time.

Walking

n Frequently: can perform activity from

Climbing

1/3 to 2/3 of the time.

Kneeling

n Constantly: can perform activity more

than 2/3 of the time.

Bending/stooping/squatting

Simple grasping

Fine manipulation

Reaching overhead

Reaching at/or below shoulder level

Driving a vehicle

Operating machinery

Temp extremes/high humidity

Environmental

Specify:

Psychiatric/neuro-behavioral (attach documentation describing functional limitations)

b. Please check the applicable category for the patient's exertional ability:

Very Heavy Work - Exerting in excess of 100 pounds of force occasionally, and/or in excess of 50 pounds of force frequently, and/or in excess of 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Heavy Work.

Heavy Work - Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Medium Work.

Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical demand requirements are in excess of those for Light Work.

Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Even though the weight lifted may only be a negligible amount, a job should be rated Light Work: (1) when it requires walking or standing to a significant degree; or (2) when it requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of those materials is negligible. NOTE: The constant stress of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.

Sedentary Work - Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

C-4.3B (11-21) Page 4

C-4.3 11-21

Patient's Name:

Last

First

Date of injury/onset of illness:______/______/______

Functional Capabilities/Exertion Abilities (continued):

c. Other medical considerations which arise from this work related injury (including the use of pain medication such as narcotics):

d. Could this patient perform his/her at-injury work activities with restrictions?		Yes	No
	If Yes, specify:

e. Could this patient perform any work activities with or without restrictions?		Yes	No
	Explain:

f. If patient is not working, could reasonable accommodations be made to enable the patient to perform work?				Yes	No
	If Yes, explain:

4. Has the patient had an injury/illness since the date of injury which impacts residual functional capacity?				Yes	No
	If Yes, explain. Attach additional sheets if necessary.

5. Would the patient benefit from vocational rehabilitation?		Yes	No
	If Yes, explain

C-4.3B (11-21) Page 5

C-4.3 11-21

IMPORTANT - TO THE ATTENDING DOCTOR

The C-4.3 has been modified to accommodate the 2018 Workers' Compensation Guidelines for Determining Impairment, while continuing to reflect the 2012 Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity. The 2018 Guidelines replace chapters in the existing 2012 Medical Impairment Guidelines Introduction and with respect to SLU. The 2012 Guidelines should continue to be used for determining non-schedule permanent impairments. This form is to be used to file reports in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefits cases as follows: 1. When rendering an opinion on MMI and/or permanent partial impairment; or 2. In response to a request by the Workers' Compensation Board to render a decision on MMI and/or permanent partial impairment.

MEDICAL REPORTING

This form must be signed by the attending doctor and must contain his/her authorization certificate number, code letters and NPI number.

A CHIROPRACTOR, PODIATRIST, PSYCHOLOGIST, NURSE PRACTITIONER OR LICENSED CLINICAL SOCIAL WORKER FILING THIS REPORT CERTIFIES THAT THE INJURY DESCRIBED CONSISTS SOLELY OF A CONDITION(S) WHICH MAY LAWFULLY BE TREATED BY THE FILING PROVIDER, AS DEFINED IN THE EDUCATION LAW AND, WHERE IT DOES NOT, THE FILING PROVIDER HAS ADVISED THE INJURED PERSON TO CONSULT A PHYSICIAN OF HIS/HER CHOICE.

HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the insurer or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.

Ask the patient if he/she has retained a legal representative. If they have retained legal representation, you are required to send copies of all reports to the patient's representative.

Instructions for Completing Section D, E, Attachment A and Attachment B

Section D. Maximum Medical Improvement

Section D includes questions regarding maximum medical improvement (MMI). For the definition of MMI, see Chapter 1.2 of the 2018 Guidelines and 2012 Guidelines. A provider who finds that the patient has met MMI should so indicate and provide the approximate date of such finding (Question 1). If the patient has not yet reached MMI so indicate (Question 1) and provide an explanation as to why additional improvement is expected and the proposed treatment plan.

Section E. Permanent Partial Impairment

Section E includes questions regarding permanent partial impairment. If there is no permanent partial impairment (Question 1) do not file this form, instead use Form C-4.2 (Dr's. Progress Report), unless requested by the Workers' Compensation Board to render a decision on MMI and/or permanent partial impairment. For more information on evaluating impairment, see Chapter 1.5 and 1.6 of the 2018 Guidelines and Chapter 9.2 of the 2012 Guidelines.

List all the body parts and/or conditions that the patient was treated for with regards to the workers' compensation claims identified in Section A of the form (Question 2). Complete either Attachment A and/or Attachment B for each body part and/or condition for which permanency exists.

Permanent Partial Disability

Attachment A and Attachment B includes questions about schedule loss of use of member or facial disfigurement (1) or Non-Schedule Permanent Partial Impairment (2). Complete Attachment A and/or Attachment B for each body part and condition for which the patient was treated. If the patient injured body parts that receive a schedule and do not receive a schedule, then complete both Attachment A and Attachment B for the appropriate body parts/conditions.

Attachment A. Schedule loss of use of member

Determine impairment % using the 2018 Workers' Compensation Guidelines for Determining Impairment. If a scheduled loss is appropriate under the 2018 Impairment Guidelines do not complete any questions in Attachment B. Attach additional sheets or narrative, if necessary. The provider should sign the Board Authorization at the bottom of page 2 and return to the Workers' Compensation Board.

Attachment B. Non-Schedule Permanent Partial Impairment

If the patient was treated for a body part and condition that is not amendable to a schedule loss of use award, record the body part, impairment table and severity letter grade for each body part or system (Question 1) using the 2012 Guidelines. Also state the history, physical findings, and diagnostic test results that support the impairment finding. If the patient has a non-schedule impairment of a body part or system that is not covered by an impairment guideline, follow Chapter 17 of the 2012 Guidelines and include the relevant history, physical findings, and diagnostic test results, but no severity letter grade.

Complete the questions regarding the patient's work status (2).

Complete the Functional Capabilities/Exertion Abilities (Question 3. a - f). Attachment B should be completed based on the patient's current condition if the provider believes there is MMI and/or permanent partial impairment or in a response to a request by the Board to render a decision on MMI and/or permanent partial impairment.

Question 3. includes questions applicable to a patient who has reached MMI and has a permanent, non-schedule impairment. For more information on evaluating functional capabilities, see Chapter 9.2 of the 2012 Guidelines. Measure and record the specific functional abilities and losses caused by the work-related medical impairment on Questions 3, a through f as follows:

Question 3a - Rate whether the patient can perform each of the fifteen functional abilities: never, occasionally, frequently, or constantly. Note the specific weight tolerances for the categories lifting/carrying and pulling/pushing. There is also room to describe any functional limitations in connection with environmental conditions (e.g., occupational asthma). Attach documentation when describing Psychiatric/neuro-behavioral functional limitations, if applicable to a patient.

Question 3b - Check the applicable category for the patient's exertional ability.

Question 3c - Note any other medical considerations arising from the permanent injury that are not captured elsewhere in Attachment B. This includes any restrictions or limitations that may be imposed as a result of medications (e.g., narcotics) taken by the patient or other relevant medical considerations that impact work function.

Question 3d - With knowledge of the patient's at-injury work activities, indicate whether the patient can perform his/her at-injury work activities with restrictions. If Yes, specifically assess the patient's ability to perform his/her at-injury work activities with restrictions.

Question 3e. Indicate whether the patient can perform any work activities with or without restrictions. Explain by providing what activities can be performed with restrictions and what work activities can be performed without restrictions.

Question 3f - Provide an explanation whether reasonable accommodations can be made for the patient.

Question 4 - Explain or attach a detailed explanation if the patient has had an intervening injury or illness that may account for any of the functional restrictions noted in Question 3a.

Question 5 - Indicate if the patient would benefit from vocational rehabilitation and if so, provide detailed explanation.

C-4.3 (11-21) INSTRUCTIONS

BILLING INFORMATION

Complete all billing information contained on this form. Use additional forms or narrative, if necessary. The workers' compensation carrier has 45 days to pay the bill or to file an objection to it. Contact the workers' compensation carrier if neither payment nor an objection are received within this time period. After contacting the carrier, if necessary, file Health Provider's Request for Decision on Unpaid Medical Bill(s) (Form HP-1). If you have questions, please contact the NYS Workers' Compensation Board at 1-800-781-2362.

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

All reports are to be filed by sending directly to the Workers' Compensation Board at the address below with a copy sent to the insurance carrier:

NYS Workers' Compensation Board - Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205

C-4.3 (11-21) INSTRUCTIONS

Click for C 4 3 File

File Breakdown

Fact Name	Description
Purpose	The C-4.3 form is used for evaluating Maximum Medical Improvement (MMI) and assessing permanent partial impairment in patients.
Submission Requirement	This form must be submitted to the Workers' Compensation Board, the insurance carrier, and the patient's attorney or representative, if applicable.
Impact of Delays	Failure to submit the form promptly may delay treatment payments and wage loss benefits for the patient and could jeopardize board authorization.
Governing Law	The C-4.3 form is governed by New York State Workers' Compensation regulations.
Online Submission	Healthcare providers can complete and submit the C-4.3 form online at www.wcb.ny.gov.

Guide to Using C 4 3

Completing the C 4 3 form requires careful attention to detail and a thorough understanding of the patient’s medical history and condition. This document assists in providing an opinion on Maximum Medical Improvement (MMI) and potential permanent partial impairment, so accuracy is vital. After filling out the form, ensure that all necessary parties, such as the Workers' Compensation Board, the insurance carrier, and the patient's attorney (if applicable), receive their copies without unnecessary delays.

Enter the date(s) of examination at the top of the form.
Fill in the WCB Case Number and Claim Admin Claim Number as required.
Patient's Information:
- Provide the patient's full name, date of birth, and Social Security Number.
- Update the patient's address if it has changed since the last report.
- Record the home phone number and the date of injury or illness.
- Include the patient's account number, if available.
Doctor's Information:
- Input your name, WCB Authorization Number, and WCB Rating Code.
- Provide your Federal Tax ID, selecting whether it is an SSN or EIN.
- Fill in the office address, billing group name, billing address, and phone numbers for both the office and billing.
- Enter the Treating Provider's NPI number.
Billing Information:
- Indicate the employer's insurance carrier and the carrier code.
- Write the insurance carrier’s address.
- Document the date of examination and include the billing (CPT) code.
- Specify the charge for the evaluation in dollars and the associated zip code.
Maximum Medical Improvement:
- Indicate if the patient has reached Maximum Medical Improvement by answering 'Yes' or 'No.'
- If 'Yes,' note the date MMI was reached. If 'No,' explain why along with the proposed treatment plan.
Permanent Partial Impairment:
- Answer whether there is permanent partial impairment.
- List the body parts and conditions treated related to the injury.
- Complete the relevant Attachments A and/or B based on the assessment and type of impairment.
Sign the form, certifying its accuracy under penalty of perjury. Include your name, signature, specialty, and the date.
Submit the form promptly to the appropriate parties.

Get Answers on C 4 3

What is the purpose of the C-4.3 form?

The C-4.3 form serves two primary purposes in the realm of workers' compensation. First, it is utilized by healthcare providers to express their opinion on whether a patient has reached Maximum Medical Improvement (MMI) and to document any permanent partial impairment. Second, this form is often requested by the Workers' Compensation Board to facilitate a determination regarding these same issues. Understanding the significance of this form is essential in ensuring proper claims processing.

Who needs to fill out the C-4.3 form?

The form must be completed by a licensed healthcare provider who is authorized by the Workers' Compensation Board. This includes doctors and other medical professionals who have treated an injured worker. Filling out this document accurately is crucial, as it provides essential information regarding the patient’s condition, treatment history, and progress.

What happens if the C-4.3 form is not submitted promptly?

A delay in submitting the C-4.3 form can lead to a variety of complications for the patient. Specifically, it may result in the postponement of necessary treatment, hinder the timely delivery of wage loss benefits, or even necessitate further testimony. Moreover, delayed submission may jeopardize the authorization status of the healthcare provider with the Board, potentially affecting their ability to treat workers' compensation patients in the future.

What kind of information is required on the C-4.3 form?

The C-4.3 form requests detailed information in several key areas:

Patient's information, including name, date of birth, and injury details.
Doctor's information, such as name, WCB authorization number, and contact details.
Details of the examination, including Maximum Medical Improvement assessment and any permanent partial impairment findings.
Billing information related to the treatment, including CPT codes and charges.

Ensuring each section is completed accurately and thoroughly will streamline the claims process.

How does a healthcare provider determine if a patient has reached Maximum Medical Improvement (MMI)?

Determining whether a patient has reached MMI involves a thorough assessment by the healthcare provider. This includes reviewing the patient's medical history, previous treatment outcomes, and current symptoms. If the patient has stabilized and further improvement is unlikely with additional treatment, the provider may conclude that the patient has reached MMI. Should the assessment indicate otherwise, the provider should outline the reasons and proposed treatment plans in detail.

What should be done if there is a need for additional documentation?

If additional documentation is required, the healthcare provider can include extra pages or attach a narrative to the C-4.3 form. This supplementary information may be necessary to clarify aspects such as the patient's condition, treatment plans, or assessments of impairment. It is crucial to ensure that all required documentation is submitted along with the initial form to avoid any processing delays.

Common mistakes

Completing the C-4.3 form can be a daunting task, and people often stumble in several areas. One common mistake is failing to provide complete patient information. Each field in the patient's information section must be filled out accurately. Inadequate details may lead to unnecessary delays in the processing of claims, which can hinder timely treatment or benefits.

Another frequent error arises from neglecting to document the date of examination properly. The date serves as a crucial reference point for claims; missing or incorrect dates can lead to confusion and disputes regarding coverage. Furthermore, many overlook the importance of including the patient's Social Security Number, which should be listed without omissions or errors. Missing this detail can further complicate claims processing.

Additionally, some practitioners forget to attach the required supplementary documents. The instructions clearly state that extra attachments may be necessary to support various claims, especially when detailing reasons for not reaching Maximum Medical Improvement (MMI). Failing to include these documents may jeopardize the validity of the submitted claim.

A significant oversight involves the *Maximum Medical Improvement* and *Permanent Partial Impairment* sections. Respondents should ensure that they answer these questions thoroughly. Misstating whether the patient has reached MMI can result in incorrect benefits assessments, while incomplete descriptions of impairments can limit the care provided.

Another pitfall occurs when a practitioner fails to adequately state the proposed treatment plan if MMI has not been reached. It's important to provide a clear plan, as this can affect the approval of ongoing medical services. If doctors only provide vague or incomplete descriptions, they risk their authorization being jeopardized.

Errors also commonly arise in the billing information section. When listing the insurance carrier details, accuracy is paramount. Mistakes here could prevent claims from being submitted correctly, leading to delayed or denied payments. Financial information including billing codes should be double-checked for compliance with established guidelines.

Inconsistent or missing details related to functional capabilities can compromise the accuracy of the form. For instance, failure to provide thorough descriptions of a patient’s residual functional capacities or an assessment of exertion abilities can lead to significant misunderstandings about the patient's capabilities and limitations.

Lastly, many individuals overlook the critical nature of signatures. Without the proper signatures, submissions are considered incomplete. It's crucial that every filling party complies with signing under penalty of perjury clause, as missing this step inherently challenges the authenticity of the information provided.

Documents used along the form

The C 4 3 form, known as the Doctor's Report of Maximum Medical Improvement (MMI) and Permanent Partial Impairment, plays a crucial role in the workers' compensation process. It is used to assess the patient's medical condition and determine eligibility for benefits. Several other forms and documents often complement the C 4 3 form, ensuring that all necessary information is collected and reported accurately.

Attachment A - Schedule Loss of Use: This document details the permanent partial impairment for specific body parts. It includes necessary information such as range of motion measurements and any prior scheduled losses of use, which help determine a schedule award for the patient.
Attachment B - Non-Schedule Award (Classification): This attachment is used when a non-scheduled permanent partial disability exists. It helps classify the impairment according to workers' compensation guidelines and provides additional information on the patient’s work status and functional capabilities.
Attending Ophthalmologist's Report (Form C-5): This report is required when there is vision loss involved. It documents the assessment and findings associated with the patient’s eye condition, contributing to the overall evaluation of the impairment.
Occupational Loss of Hearing (C-72.1): This form is specific to patients dealing with occupational hearing loss. It outlines the extent and nature of hearing impairment related to workplace exposure, supplementing the information provided in the C 4 3 form.

Each of these forms and documents is vital in ensuring that the patient’s case is handled appropriately, facilitating access to benefits and support. Accurate completion and timely submission can significantly impact the outcome for the injured worker.

Similar forms

Form C-4.2: Medical Report - Similar to the C-4.3 form, the C-4.2 form documents medical evaluations related to a worker's injury. Both forms require detailed information about the patient's condition, treatment history, and impairment status.
Form C-5: Attending Ophthalmologist's Report - This form is used when a patient has vision loss due to a workplace injury, similar to the C-4.3 form that addresses various impairments. Both forms demand clinical assessments to support claims for compensation.
Form C-72.1: Occupational Loss of Hearing - This document specifically evaluates hearing loss as a result of occupational hazards, aligning with the C-4.3 form's focus on permanent partial impairments. Both forms engage detailed medical analyses to substantiate the claims.
Form C-4.4: Doctor's Report for Permanent Total Disability - This report assesses conditions leading to permanent total disability, complementing the C-4.3’s focus on partial impairment. Both emphasize medical opinions regarding the patient's ability to return to work.
Form C-3: Employee's Claim for Compensation - This form facilitates the initiation of a claim for workers’ compensation, which often involves information related to the assessments documented in the C-4.3 form. Both are integral to the claims process, requiring precise details from medical professionals.
Form C-4.6: Work Status Report - This document addresses the patient’s current ability to work, paralleling the C-4.3 form that evaluates maximum medical improvement. Both forms help determine the necessary support for the injured worker during their recovery process.

Dos and Don'ts

When filling out the C-4.3 form, it is critical to ensure that all information is accurate and complete. Below is a list of things to do and avoid during the process.

Do provide accurate dates, including examination date and date of injury.
Do check that all sections of the form are filled out completely to avoid delays.
Do attach any additional pages if more space is needed for your answers.
Do submit the form promptly to all relevant parties, such as the Workers' Compensation Board and the patient's attorney.
Do ensure that you include your WCB Authorization number accurately.

Don't leave any questions unanswered; incomplete forms can lead to processing delays.
Don't use jargon or abbreviation that may confuse readers outside the medical field.
Don't disregard the patient's confidentiality; ensure personal information is properly handled.
Don't submit the form without reviewing it for errors to ensure the utmost accuracy.

Misconceptions

Misconceptions about the C-4.3 Form

It is only needed for severe injuries. Many believe the C-4.3 form is reserved for serious injuries. In reality, it is required for any situation where an opinion on Maximum Medical Improvement (MMI) or permanent partial impairment is needed, regardless of the injury's severity.
Doctors can submit the form any time. Some think there is flexibility in when to submit the C-4.3. Timely submission is crucial as delays can hinder treatment and benefit payments.
Only one copy of the form is necessary. There is a misconception that submitting a single copy to the Workers’ Compensation Board suffices. In fact, copies should also be sent to the insurance carrier and, if applicable, to the patient’s attorney or representative.
Maximum Medical Improvement (MMI) means the patient is fully healed. Many assume that reaching MMI implies complete recovery. However, MMI simply indicates that a patient's condition has stabilized, and they are unlikely to improve significantly with further treatment.
The form is the same for all injuries. Some people think that the C-4.3 form is a one-size-fits-all document. The truth is that completing specific attachments relevant to the type and location of injury is necessary for accuracy.
Completing the form is straightforward. A common belief is that filling out the C-4.3 is easy. While the format may seem simple, it requires detailed medical input and careful documentation of the patient's condition, which can be complex.
Only doctors can complete the form. Some assume only a physician can fill out the C-4.3. While a medical provider must sign it, other authorized health care professionals can also assist in completing the required sections.
All injuries should be reported on a single form. A misconception exists that the C-4.3 can encompass all injuries a patient might have. In reality, different injuries or conditions often necessitate separate attachments for proper classification and evaluation.
Once submitted, the form cannot be changed. Lastly, a belief that the C-4.3 is unchangeable once submitted can cause apprehension. While changes should be made carefully, it is possible to amend submissions if new medical information arises.

Key takeaways

The C-4.3 form is used by healthcare providers to report on a patient's maximum medical improvement (MMI) and any permanent partial impairment.
This form is required when a provider renders an opinion on a patient’s condition or responds to a request from the Workers' Compensation Board.
Complete all sections of the form thoroughly, providing extra documentation if needed to ensure clarity and accuracy.
Submit the completed form promptly to the necessary parties including the Board, the insurance carrier, and the patient’s representative.
Filling out the C-4.3 form online is an option available at www.wcb.ny.gov, which can simplify the process.
Be sure to clearly indicate if the patient has reached MMI and provide a proposed treatment plan if they have not.
Attachments are necessary for detailed reporting of specific body parts and conditions treated, enabling better assessment for disability awards.