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Ancillary Report Online 2015-2023
Licensed representative if he/she has one if not send a copy to the patient. Failure to do so may delay the payment of necessary services 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* A. Patient s Information 1. Name Last First 3. Mailing address - 2. Soc* Sec* MI Number and Street City State Zip Code 4. Home phone 5. Date of Birth //...Show details
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