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C4 Auth Form

C4 Auth Form

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What is the C4 Auth

The C4 Auth, or the Workers Compensation C-4 Authorization form, is a crucial document used in the New York workers' compensation system. It serves as an authorization for medical providers to release treatment information related to an injured worker's claim. This form is essential for ensuring that all relevant medical records are accessible to the insurance carrier and the Workers' Compensation Board, facilitating the claims process.

How to use the C4 Auth

Using the C4 Auth involves several steps to ensure proper completion and submission. First, the injured worker must fill out their personal information and details about the injury. Next, the worker must provide the names of the healthcare providers who treated them. Once completed, the form must be signed and dated by the injured worker, granting permission for the release of their medical records. It is important to ensure that all sections are accurately filled to avoid delays in the claims process.

Steps to complete the C4 Auth

Completing the C4 Auth requires careful attention to detail. Here are the steps to follow:

  • Begin by entering your full name, address, and contact information.
  • Provide the date of the injury and a brief description of the incident.
  • List all medical providers who have treated you for the injury, including their contact information.
  • Sign and date the form to authorize the release of your medical records.
  • Review the completed form for accuracy before submission.

Legal use of the C4 Auth

The C4 Auth is legally binding when properly completed and signed by the injured worker. It complies with the regulations set forth by the New York Workers' Compensation Board, ensuring that medical information can be shared with the appropriate parties involved in the claim. This legal framework protects both the rights of the injured worker and the interests of the insurance carrier.

Key elements of the C4 Auth

Several key elements must be included in the C4 Auth to ensure its validity:

  • Personal Information: Full name, address, and contact details of the injured worker.
  • Injury Details: Date and description of the injury.
  • Provider Information: Names and contact details of all healthcare providers involved in the treatment.
  • Signature: The injured worker's signature and date, confirming the authorization.

Form Submission Methods

The C4 Auth can be submitted through various methods to ensure it reaches the appropriate parties. Options include:

  • Online Submission: Many insurance carriers allow for electronic submission through their platforms.
  • Mail: The completed form can be mailed directly to the insurance carrier or the Workers' Compensation Board.
  • In-Person: Submitting the form in person at the local Workers' Compensation Board office is also an option.

Quick guide on how to complete c4 form

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