Workers' Compensation Guidelines for Determining …
Legislation enacted in April 2017 [WCL§15(3)(x)] directed the Board to consult with “representatives of labor, business, medical providers, insurance carriers, and self-insured
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www.wcb.ny.govWCB Case Number (if known):Balance Due (Carrier Use Only)Amount Paid Total Charge Use WCB Codes$Dates of ServiceFrom MM DD YY To MM DD YYPlace of
PLEASE READ CAREFULLY THE FOLLOWING …
www.wcb.ny.govThe undersigned requests written authorization for the following special service(s) costing over $1,000 or requiring pre-authorization pursuant to …
COVER SHEET FOR REPORT OF INDEPENDENT …
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www.wcb.ny.govI request that the Workers' Compensation Board review the insurer's denial of my doctor's request for approval to vary from the Medical Treatment Guidelines.
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