For workers' claims in New York that result in the permanent impairment of a patient, the C4.3 form, or Doctor's Report of MMI/Permanent Impairment form is required. This form is built into your DrChrono account and is easily accessible through the patient's appointment.
- Navigate to the patient's appointment
- Make sure the payment profile is set to Workers' Comp. Also, ensure all fields are filled in under the Workers' Comp section under the patient's insurance.
- Select Other Forms on the right side of the screen
Here you can select and print a couple of related forms.
HCFA/1500 - This is a regular 1500 form that will print on plain white 8.5" X 11" paper
HCFA/1500 (text) - This will print just the text. Select this option if you have the red pre-printed HCFA paper in your printer.
New York: C4.3 - Doctor's Report of MMI/Permanent Impairment
New York: NF3 - New York Motor Vehicle No-Fault Insurance Law Verification of Treatment by Attending Physician or Other Provider of Health Service
Doctor's Report of MMI/Permanent Impairment
When you select the C4.3 form from the dropdown, many fields will pre-populate if the information is listed in the patient's Workers' Compensation insurance section. If it is not, or you need to update the information shown, you can click into the box and it will let you free text.
All patient data listed in this article is sample data. This is not a real person or real patient data.
Source: https://www.dfs.ny.gov/apps_and_licensing/property_insurers/nofault