Form MG-1.1 "Continuation to Form Mg-1, Attending Doctor's Request for Optional Prior Approval" - New York

What Is Form MG-1.1?

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 April 1, 2018;
  • 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 MG-1.1 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 MG-1.1 "Continuation to Form Mg-1, Attending Doctor's Request for Optional Prior Approval" - New York

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MG-1.1
CONTINUATION TO FORM MG-1, ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL
WCB Case #:
Claim Administrator Claim (Carrier Case) #:
Date of Injury/Illness:
Patient's Name:
Social Security No.:
Doctor's Name:
WCB Authorization No.:
NPI No.:
INSTRUCTIONS TO ATTENDING DOCTOR: This form must be filed attached to a completed Form MG-1 if requesting
optional prior approval for additional treatment(s) or procedure(s) in the same case.
A.
The undersigned requests additional optional approval under the WCB Medical Treatment Guidelines as indicated below:
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
2.
RESPONSE
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
-
Guideline Reference:
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining boxes,
indicate corresponding section of WCB Medical Treatment Guidelines. If the
certification on reverse of this form)
treatment requested is not addressed by the Guidelines, in the remaining boxes
use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Comments:
Granted without Prejudice
Denied
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
3.
RESPONSE
-
Guideline Reference:
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining
boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If
certification on reverse of this form)
the treatment requested is not addressed by the Guidelines, in the remaining
boxes use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Comments:
Granted without Prejudice
Denied
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
4.
RESPONSE
-
Guideline Reference:
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining
boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If
certification on reverse of this form)
the treatment requested is not addressed by the Guidelines, in the remaining
boxes use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Comments:
Granted without Prejudice
Denied
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
5.
RESPONSE
-
Guideline Reference:
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining
boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If
certification on reverse of this form)
the treatment requested is not addressed by the Guidelines, in the remaining
boxes use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Granted without Prejudice
Comments:
Denied
I certify that I am making the above request for optional prior approval and my affirmative statements are true and correct.
A copy was sent to the Workers' Compensation Board, and copies were provided to the claimant's legal representative, if any, and to any other parties of
interest on the date below.
Provider's Signature:
Date:
MG-1.1 (4-18)
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
MG-1.1 4-18
MG-1.1
CONTINUATION TO FORM MG-1, ATTENDING DOCTOR'S REQUEST FOR OPTIONAL PRIOR APPROVAL
WCB Case #:
Claim Administrator Claim (Carrier Case) #:
Date of Injury/Illness:
Patient's Name:
Social Security No.:
Doctor's Name:
WCB Authorization No.:
NPI No.:
INSTRUCTIONS TO ATTENDING DOCTOR: This form must be filed attached to a completed Form MG-1 if requesting
optional prior approval for additional treatment(s) or procedure(s) in the same case.
A.
The undersigned requests additional optional approval under the WCB Medical Treatment Guidelines as indicated below:
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
2.
RESPONSE
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
-
Guideline Reference:
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining boxes,
indicate corresponding section of WCB Medical Treatment Guidelines. If the
certification on reverse of this form)
treatment requested is not addressed by the Guidelines, in the remaining boxes
use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Comments:
Granted without Prejudice
Denied
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
3.
RESPONSE
-
Guideline Reference:
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining
boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If
certification on reverse of this form)
the treatment requested is not addressed by the Guidelines, in the remaining
boxes use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Comments:
Granted without Prejudice
Denied
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
4.
RESPONSE
-
Guideline Reference:
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining
boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If
certification on reverse of this form)
the treatment requested is not addressed by the Guidelines, in the remaining
boxes use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Comments:
Granted without Prejudice
Denied
INSURER'S/EMPLOYER'S
Treatment/Procedure Requested
5.
RESPONSE
-
Guideline Reference:
(In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and
(Insurer/employer must complete
Low Back, N = Neck, C = Carpal Tunnel, P = Non-Acute Pain. In remaining
boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If
certification on reverse of this form)
the treatment requested is not addressed by the Guidelines, in the remaining
boxes use NONE.)
Date of service of supporting medical in WCB case file, if not attached:
Granted
Granted without Prejudice
Comments:
Denied
I certify that I am making the above request for optional prior approval and my affirmative statements are true and correct.
A copy was sent to the Workers' Compensation Board, and copies were provided to the claimant's legal representative, if any, and to any other parties of
interest on the date below.
Provider's Signature:
Date:
MG-1.1 (4-18)
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
MG-1.1 4-18
B.
INSURER'S / EMPLOYER'S RESPONSE
(Response is due within 8 business days of receipt of this request or medical care is deemed approved (12 NYCRR 324
(c)). IF ANY REQUESTS ARE DENIED, GIVE REASON(S) IN THE SPACE PROVIDED BELOW. Identify reasons according to Request No. 2-5 on the front of this form.
Name of the medical professional who reviewed the denial(s):
I certify that copies of this form were sent to the Treating Medical Provider requesting optional prior approval, the Workers' Compensation Board (see mailing and email
addresses and fax number on Form MG-1), the claimant's legal representative, if any, and any other parties of interest, on the date below.
By: (print name)
Title:
Signature:
Date:
C.
MEDICAL PROVIDER'S REQUEST FOR BOARD REVIEW OF DENIAL
I hereby request review by a medical arbitrator designated by the Chair of the insurers decision to deny optional prior approval of the request(s) checked below. I
understand that resolution by the medical arbitrator is binding and is not appealable under Workers' Compensation Law Section 23. (Request is due within 14
calendar days of the date of denial.) Supporting medical report(s) dated
is/are attached or is/are available in the WCB case file.
Request No. 2
Request No. 3
Request No. 4
Request No. 5
Provider's Signature:
Date:
D.
INSURER / EMPLOYER IS APPROVING ADDITIONAL REQUEST(S) FOR OPTIONAL PRIOR APPROVAL AFTER AN INITIAL DENIAL
I certify that the provider's request for optional prior approval given above, which was initially denied on
, is now granted for the
following request(s):
Request No. 2
Request No. 3
Request No. 4
Request No. 5
By: (print name)
Title:
Signature:
Date:
MG-1.1 (4-18)
www.wcb.ny.gov
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