A C4 Form is a workers’ compensation board form titled “Attending Doctor’s Report,” that requests information about claimaint/claim identification, claim parties of interest, injury history, diagnosis, treatment, disability, causal relation of accident to disability, and degree of impairment˳ The form is to be filed by the doctor within 15 days of the initial treatment, with additional reports during treatment, and a final report at the completion of treatment˳ Once the initial form is filed, subsequent visits should be billed out within 45 days of the visit˳
C4 forms are required when billing for services related to workers’ compensation, or when a patient was injured on the job˳ Many practice management systems come with these forms as a standard insurance form listed in the insurance form menu of the program˳ That is the easiest way to submit them˳ You actually print the claim on white paper, and the program not only prints up the charges and other information, but actually creates the form too˳
If your practice management system does not have the form available, you can usually get a blank form online through your state’s website˳
Once you have a blank form, you can either type the information in, or if your software has the capabilities, you can program your software to fill in the boxes on the form˳ In any case, you will need to submit a copy directly to the workers’ compensation carrier, and the state workers’ compensation board as well˳
It is extremely important that all boxes on the C4 form are completed accurately˳ A copy of the form is submitted to the state workers’ compensation board and those forms are usually scanned into a computer system˳ When or if a case goes to a hearing, the information on these forms is used˳ If the information is not completed, or is not accurate, it can adversely affect the outcome of the hearing˳ For example, if the doctor does not complete the box indicating the patient is disabled, and the patient is truly disabled, the employers lawyers can argue that the disability has not been established˳ So even leaving a field blank can be detrimental˳
The forms are fairly easy to fill out and are pretty self explanatory˳
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