Form C-4.1 "Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or Ot/Pt-4" - New York

What Is Form C-4.1?

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 September 1, 2008;
  • 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form C-4.1 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 C-4.1 "Continuation to Carrier/Employer Billing Section of Form C-4, C-4.2, C-4.3, C-5, PS-4 or Ot/Pt-4" - New York

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CONTINUATION TO CARRIER/EMPLOYER BILLING PORTION
OF FORMS C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4
Doctor's Name
Carrier Case Number
Date of Accident or Injury
WCB Case Number
Patient
Patient's Social Security Number:
A
B
C
D
(USE WCB CODE)
E
H
F
G
I
Dates of
Service
Place
Leave
Days or
Zip Code Where Service was
Procedures, Services or Supplies
From
To
COB
of
Diagnosis Code
$ Charges
Blank
Units
Rendered
MM
DD
YY
MM
DD
YY
Service
CPT/HCPCS
MODIFIER
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19..
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
THE INJURED WORKER SHOULD NOT PAY THIS BILL
.
C-4.1 (9-08)
NY-WCB
CONTINUATION TO CARRIER/EMPLOYER BILLING PORTION
OF FORMS C-4, C-4.2, C-4.3, C-5, PS-4 or OT/PT-4
Doctor's Name
Carrier Case Number
Date of Accident or Injury
WCB Case Number
Patient
Patient's Social Security Number:
A
B
C
D
(USE WCB CODE)
E
H
F
G
I
Dates of
Service
Place
Leave
Days or
Zip Code Where Service was
Procedures, Services or Supplies
From
To
COB
of
Diagnosis Code
$ Charges
Blank
Units
Rendered
MM
DD
YY
MM
DD
YY
Service
CPT/HCPCS
MODIFIER
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19..
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
THE INJURED WORKER SHOULD NOT PAY THIS BILL
.
C-4.1 (9-08)
NY-WCB