Updated Form C-4.3

Please be advised that the instructions on the Doctor’s Report of MMI/Permanent Impairment (Form C-4.3) (link) have been updated and a section requesting billing information has been removed.

While the paper (electronically fillable) version of the form will still be available on the NYS Workers’ Compensation Board’s (Board’s) website, the online submission option through the Board’s website has been removed.

Medical bills for permanency evaluations must be submitted electronically using a Board-approved electronic submission partner by attaching a completed Form C-4.3 to the CMS-1500 form as the medical narrative. Providers should only use one of the CPT codes that are approved for permanency evaluations (99243 or 99245) on the medical bill to bill for such services.

Providers should work with their electronic submission partner to determine the best method for attaching medical narratives to the CMS-1500 form. Do not send Form C-4.3 separately to the Board. The submission partner is responsible for sending both the CMS-1500 form and Form C-4.3 to the Board and payer electronically.

CMS-1500 ELECTRONIC SUBMISSION

As previously communicated, effective August 1, 2025, all treating health care providers in the workers' compensation system — regardless of office size or patient population — must submit the CMS-1500 universal medical billing form electronically through a Board-approved electronic submission partner in order to be paid for services. This applies to each individual provider in a practice who treats workers’ compensation patients.

If you have not obtained an electronic submission partner, we urge you to do so immediately.

MORE INFORMATION

Visit the Board’s website for a complete list of Board forms and for more information on CMS-1500.

If you have not already, be sure to sign up to receive Board news straight to your inbox.

Questions? Email CMS1500@wcb.ny.gov.