A C4 form is a form from the workers’ compensation board titled “Physician Assistant Report” that requests information about the claim / claim identification, claim stakeholders, injury history, diagnosis, treatment, disability, the causal relationship of the accident with the disability and the degree of disability. The form must be submitted by the physician within 15 days of the initial treatment, with additional reports during treatment and a final report at the end of treatment. Once the initial form is submitted, subsequent visits must be billed within 45 days of the visit.
C4 forms are required when billing for workers’ compensation related services or when a patient is injured on the job. Many practice management systems come with these forms as a standard insurance form listed in the program’s insurance forms menu. That is the easiest way to send them. In fact, you print the claim on white paper and the program not only prints the charges and other information, but also creates the form.
If your practice management system does not have the form available, you can usually obtain a blank form online through your state’s website.
Once you have a blank form, you can either enter the information or, if your software has the capabilities, you can program your software to fill in the form boxes. In either case, you will need to send a copy directly to the workers ‘compensation company and also to the state workers’ compensation board.
It is extremely important that all boxes on Form C4 are completed accurately. A copy of the form is sent to the state workers’ compensation board and those forms are usually scanned into a computer system. When or if a case goes to a hearing, the information from these forms is used. If the information is not complete or accurate, it may negatively affect the outcome of the hearing. For example, if the physician does not complete the box indicating that the patient is disabled, and the patient is actually disabled, the employers’ attorneys may argue that the disability has not been established. Therefore, even leaving a field blank can be detrimental.
The forms are fairly easy to fill out and are self explanatory.
