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

What Is Form MD-3?

This is a legal form that was released by the New York State Workers' Compensation Board - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2011;
  • The latest edition provided by the New York State Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form MD-3 by clicking the link below or browse more documents and templates provided by the New York State Workers' Compensation Board.

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

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STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205
CARRIER'S/SELF -INSURED EMPLOYER'S OBJECTION TO ATTENDING DOCTOR'S
REQUEST FOR MEDICAL AUTHORIZATION DETERMINATION
WCB Case Number
Carrier Case Number
Carrier Code
Date of Injury
Social Security Number
Name
Address
imant
Cla
Employer
Carrier
Representative, If Any
Medical Provider Requesting
Authorization on Form MD -1
Insurance Carrier/Self-Insured Employer making objection:
Date Form MD -1 Mailed:
Basis for Objection:
Signature: ________________________________ Tel. No.:
Date:
(Ink only - Use blue ballpoint pen if possible.)
Signer's Name and Title (Please Print):________________________________________________
TO THE SIGNER: The original should be sent directly to the Workers' Compensation Board at the address
shown at the top of this form. A copy of this objection must be sent to all parties in interest and the medical
provider who requested authorization. Complete the Affidavit or Affirmation of Service on the reverse side
of this form.
MD -3 (1-11)
www.wcb.ny.gov
STATE OF NEW YORK
WORKERS' COMPENSATION BOARD
NYS Workers' Compensation Board, Centralized Mailing, PO Box 5205, Binghamton, NY 13902-5205
CARRIER'S/SELF -INSURED EMPLOYER'S OBJECTION TO ATTENDING DOCTOR'S
REQUEST FOR MEDICAL AUTHORIZATION DETERMINATION
WCB Case Number
Carrier Case Number
Carrier Code
Date of Injury
Social Security Number
Name
Address
imant
Cla
Employer
Carrier
Representative, If Any
Medical Provider Requesting
Authorization on Form MD -1
Insurance Carrier/Self-Insured Employer making objection:
Date Form MD -1 Mailed:
Basis for Objection:
Signature: ________________________________ Tel. No.:
Date:
(Ink only - Use blue ballpoint pen if possible.)
Signer's Name and Title (Please Print):________________________________________________
TO THE SIGNER: The original should be sent directly to the Workers' Compensation Board at the address
shown at the top of this form. A copy of this objection must be sent to all parties in interest and the medical
provider who requested authorization. Complete the Affidavit or Affirmation of Service on the reverse side
of this form.
MD -3 (1-11)
www.wcb.ny.gov
AFFIRMATION OF SERVICE
STATE OF NEW YORK, COUNTY OF _________________________ ss:
I, the undersigned, am an attorney admitted to practice in the courts of New York State, and on __________________, I served a
date
true copy of this form and attachments in the following manner (check one):
By mailing the same in a sealed envelope, with postage prepaid thereon, in a post -office or official depository of
Service by
Mail
the U.S. Postal Service within the State of New York, addressed to the last known address of the addressee(s) as
indicated below:
Personal
By delivering the same personally to the persons and at the addresses indicated below:
Service
I affirm that the foregoing statements are true under penalties of perjury.
_____________________________________________________
Signature
Dated: _________________
_____________________________________________________
Signer's Name (Please Print)
AFFIDAVIT OF SERVICE
STATE OF NEW YORK, COUNTY OF __________________________ ss:
_______________________________________________ being sworn says: I am over 18 years of age and on
__________________, I served a true copy of this form and attachments in the following manner (check one):
date
By mailing the same in a sealed envelope, with postage prepaid thereon, in a post -office or official depository of
Service
by Mail
the U.S. Postal Service within the State of New York, addressed to the last known address of the addressee(s) as
indicated below:
Personal
By delivering the same personally to the persons and at the addresses indicated below:
Service
Sworn to before me on _____________________. ______________________________________________________________
Date
Signature
________________________________________ _______________________________________________________________
Notary Public
Signer's Name (Please Print
MD -3 (1-11) Reverse
www.wcb.ny.gov
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