C-4Doctor's Initial Report of Injury

Clinicians fill out · Submitted to regulator · Employers file

When it’s used

Initial treatment (C-4 within 48 hours of first treatment); progress report (C-4.2 at 15 days after first treatment, then at each follow-up visit but not more than 90 days apart); MMI/permanent impairment (C-4.3 when rendering opinion on MMI and/or permanent impairment, or in response to Board request)

Who fills it out

Treating physician of record. NPs may sign C-4, C-4.2, and C-4.3 as authorized providers under WCL §13-b. PAs may sign C-4.2 and C-4.3 but PA services on C-4.3 may only be provided under the direct supervision of a physician. PAs are not listed as authorized filers for the initial C-4 report.

Who signs

NPs may sign C-4, C-4.2, and C-4.3 as authorized providers under WCL §13-b. PAs may sign C-4.2 and C-4.3 but PA services on C-4.3 may only be provided under the direct supervision of a physician. PAs are not listed as authorized filers for the initial C-4 report.

Where it goes

C-4: within 48 hours of first treatment; C-4.2: 15-day report after first treatment, then at each medically necessary follow-up visit, not more than 90 days apart; C-4.3: when MMI reached or upon Board request. As of 7/1/22, CMS-1500 should be used for billing with medical narrative attached.

Electronic submission

Supported — WCB Medical Portal for online submission of C-4 and C-4.2 forms. As of 7/1/22, CMS-1500 is the primary billing vehicle. C-4.3 must be attached to electronically submitted CMS-1500 as the medical narrative. EC-4NARR available for online narrative reports. Board does not normally accept electronic signatures on Board-prescribed forms (ink signature required).

Narrative substitution

EC-4NARR (Doctor's Narrative Report) may be used in lieu of C-4/C-4.2 for first treatment, 15-day, and follow-up reports if attaching a detailed narrative. Narrative must address specific required topics per WCB Attachment Requirements. For MMI, only Form C-4.3 is accepted.