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Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.wcb.ny.gov. Date(s) of Examination:_______/_______/_______ WCB Case # (if known): Carrier Case #: A. Patient's Information 1. Name: Last First 4. Address (if changed from previous report) : - 2. Date of Birth: _____/_____/_____ 3....

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NY C-4.3 2021

4.6 Satisfied (56 Votes)

NY C-4.3 2018

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NY C-4.3 2015

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NY C-4.3 2008

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