New York State Workers' Compensation Board Forms

223
total templates

Documents

223

Form CE-200APPLY "Application for Certificate of Attestation of Exemption" - New York

Rate (4.4 / 5) 9 votes
Size: 321 KB
6 pages

New York State entities who want to be exempted from liability to carry their workers' compensation or disability benefits insurance may use this form to apply for the exemption.

Form C-3 "Employee Claim" - New York (Haitian Creole)

Rate (4.5 / 5) 24 votes
Size: 429 KB
4 pages

Formulario C-3 "Reclamo Del Empleado" - New York (Spanish)

Rate (4.3 / 5) 26 votes
Size: 387 KB
4 pages

Form MR/IME-1 "Health Provider's Application for Authorization Under the Workers' Compensation Law" - New York

Rate (4.4 / 5) 12 votes
Size: 176 KB
2 pages

Form HIMP-1 "New York State Workers' Compensation Board Health Insurance Matching Program" - New York

Rate (4.5 / 5) 34 votes
Size: 1 MB
2 pages

Form IME-5 "Claimant's Notice of Independent Medical Examination" - New York

Rate (4.8 / 5) 24 votes
Size: 2 MB
2 pages

Form IME-4 "Independent Examiner's Report of Independent Medical Examination" - New York

Rate (4.4 / 5) 9 votes
Size: 2 MB
2 pages

Form MG-1 "Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response" - New York

Rate (4.4 / 5) 16 votes
Size: 2 MB
3 pages

Form MG-2 "Attending Doctor's Request for Approval of Variance and Carrier's Response" - New York

Rate (4.8 / 5) 20 votes
Size: 2 MB
5 pages

Form WTCVol-3 "World Trade Center Volunteer's Claim for Compensation" - New York

Rate (4.5 / 5) 28 votes
Size: 1 MB
2 pages

Form RFA-2 "Request for Further Action by Carrier/Employer" - New York

Rate (4.8 / 5) 23 votes
Size: 1 MB
2 pages

Form AFF-1 "Affidavit for Death Benefits" - New York

Rate (4.6 / 5) 68 votes
Size: 409 KB
11 pages

Form OT/PT-4 "Occupational/ Physical Therapist's Report" - New York

Rate (4.6 / 5) 37 votes
Size: 427 KB
2 pages

Form PS-4 "Attending Psychologist's Report" - New York

Rate (4.4 / 5) 19 votes
Size: 1 MB
2 pages

Form C-5 "Attending Ophthalmologist's Report" - New York

Rate (4.7 / 5) 23 votes
Size: 1 MB
2 pages

Form DD-1 "Direct Deposit and Debit Card Authorization Form" - New York

Rate (4.6 / 5) 61 votes
Size: 2 MB
2 pages

Form IME-7 "Statement of Registration" - New York

Rate (4.4 / 5) 92 votes
Size: 2 MB
2 pages

Form IME-3 "Independent Examiner's Report of Request for Information/Response to Request Regarding Independent Medical Examination" - New York

Rate (4.5 / 5) 50 votes
Size: 2 MB
1 page

Form IS-1 "Physician's Application for Designation as an Impartial Specialist" - New York

Rate (4.3 / 5) 52 votes
Size: 1 MB
2 pages

Form IS-4 "Report of Impartial Specialist Examination or Record Review" - New York

Rate (4.7 / 5) 77 votes
Size: 2 MB
2 pages

Form VDF-1 "Loss of Wage Earning Capacity Vocational Data Form" - New York (Chinese)

Rate (4.5 / 5) 22 votes
Size: 1 MB
2 pages

Form DT-1 "Notice That Claimant Must Arrange for Diagnostic Tests & Examinations Through a Network Provider" - New York

Rate (4.7 / 5) 23 votes
Size: 1 MB
1 page

Form VDF-1 "Loss of Wage Earning Capacity Vocational Data Form" - New York

Rate (4.8 / 5) 93 votes
Size: 2 MB
2 pages

Form VAW-3 "Volunteer Ambulance Worker's Claim for Benefits" - New York

Rate (4.6 / 5) 12 votes
Size: 2 MB
2 pages

Form VF-3 "Volunteer Firefighter's Claim for Benefits" - New York

Rate (4.6 / 5) 20 votes
Size: 2 MB
2 pages

Form MR-4 "Impartial Specialist's Report of Medical Records Review" - New York

Rate (4.8 / 5) 100 votes
Size: 1 MB
2 pages

Form MD-1 "Attending Doctor's Request for Medical Authorization Determination" - New York

Rate (4.4 / 5) 67 votes
Size: 1 MB
2 pages

Form ADR-1 "Report of Work-Related Injury or Occupational Disease" - New York

Rate (4.8 / 5) 88 votes
Size: 1 MB
2 pages

Form ADR-2 "Alternative Dispute Resolution Program Final Disposition or Settlement of Claim" - New York

Rate (4.5 / 5) 35 votes
Size: 2 MB
2 pages

Form MD-3 "Carrier's/Self-insured Employer's Objection to Attending Doctor's Request for Medical Authorization Determination" - New York

Rate (4.5 / 5) 59 votes
Size: 1 MB
2 pages

Form C-2 "Employer's Report of Work-Related Injury/Illness" - New York

Rate (4.6 / 5) 11 votes
Size: 2 MB
6 pages

Form HP-J1 "Provider's Request for Judgment of Award, Section 54-b, Enforcement on Failure to Pay Award or Judgment" - New York

Rate (4.7 / 5) 18 votes
Size: 257 KB
1 page

Form A-9 "Notice That You May Be Responsible for Medical Costs in the Event of Failure to Prosecute, or if Compensation Claim Is Disallowed, or if Agreement Pursuant to Wcl 32 Is Approved" - New York (English/Spanish)

Rate (4.6 / 5) 33 votes
Size: 94 KB
2 pages

Form DD-2 "Biannual Recertification to Entitlement to Benefits" - New York

Rate (4.8 / 5) 66 votes
Size: 54 KB
2 pages

Form R "Carrier's Report on Rehabilitation" - New York

Rate (4.7 / 5) 34 votes
Size: 156 KB
1 page

Form HP-4 "Notice to Chair: Health Provider's and Insurer's Withdrawal of Request for Arbitration" - New York

Rate (4.4 / 5) 34 votes
Size: 128 KB
2 pages

Form HIPAA-1 "Claimant's Authorization to Disclose Health Information (Pursuant to Hipaa)" - New York

Rate (4.8 / 5) 15 votes
Size: 34 KB
1 page

Form VAW-1 "Notice to Liable Political Subdivision of Volunteer Ambulance Worker's Injury or Death" - New York

Rate (4.7 / 5) 66 votes
Size: 22 KB
1 page

Form VF-1 "Notice to Liable Political Subdivision of Volunteer Firefighter's Injury or Death" - New York

Rate (4.5 / 5) 27 votes
Size: 21 KB
1 page

Instructions for Form C-3 "Employee Claim" - New York

Rate (4.6 / 5) 22 votes
Size: 236 KB
2 pages