New York State Workers' Compensation Board Forms

This form is used for attorneys or licensed representatives to request to withdraw from representing a client in New York.

This Form is used for doctors in New York to submit their initial report. It is a required document for reporting medical conditions and treatments.

This Form is used for requesting a decision on unpaid medical bills in New York.

This form is used for practitioners in New York to report the results of a Functional Capacity Evaluation (FCE) for individuals. It helps assess the individual's physical abilities and limitations in order to make informed decisions related to their work or disability benefits.

This form is used for notifying workers in New York of their right to choose a healthcare provider authorized by the Workers' Compensation Board. The form is available in both English and Arabic.

This document is a settlement agreement form used in New York for workers' compensation cases involving indemnity payments only. It is available in Arabic.

This document is used for filing an affidavit to claim death benefits in New York. It is available in Arabic language.

This form is used for filing a claim for compensation in a death case in New York. It is available in Arabic.

This Form is used for filing a language access complaint in New York.

This Form is used to notify individuals in New York (Spanish) that they may be responsible for medical costs if their compensation claim is disallowed or if an agreement under WCL 32 is approved.

This form is used in New York to notify individuals that they may be responsible for medical costs if their compensation claim is disallowed or if they fail to prosecute. It also applies if an agreement pursuant to WCL 32 is approved.