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Understanding the Workers’ Compensation Forms

Monday, April 8, 2019

There are over 30 different forms used in the New York State Workers’ Compensation system. Some are fairly simple and straightforward while others are quite complicated and require the expertise of an attorney or claims professional. Here is a short list of forms which every injured worker should be familiar with. All of these forms are available on the New York State Workers’ Compensation Board website: www.wcb.ny.gov/forms.

 Form C-3

This is the form which every injured worker should complete and submit to the New York State Workers’ Compensation Board immediately after his or her injury, even though the law says that you have two years from the date of accident to file. It covers all of the basic details about your claim: your information, your employer’s information, your salary, accident description(when, where, what and how), parts of the body injured, how and when your employer was notified, time lost from work, medical treatment and prior injuries. After completing the form it can be filed electronically (online), by fax, by  mail or by personal delivery to a local office of the Workers’ Compensation Board. Always keep a copy and make sure to get some kind of proof that you filed; an email or fax delivery confirmation or a stamped copy from the Workers’ Compensation Board.

FORM C-4

This is the initial form prepared and filed by your health care provider and covers all of the information about your injury: how the accident happened, the first date of treatment, the diagnosis, whether the injury is related to your accident, whether or not you are disabled and to what extent and the course of treatment planned. Although the injured worker provides much of the information contained in this form, he or she is not involved in its preparation or filing. However, it is important to make sure that the healthcare provider is filing properly as it will impact on the injured worker’s benefits. There two other important forms, The C-4.2, which is the progress report submitted by the healthcare provider and The C4.3, which the healthcare provider submits if the injury is permanent. Again, it is important to be sure that the injured worker’s healthcare provider is properly preparing and filing these documents to avoid any interruption in benefits.

Form OC-110A

 Your workers’ compensation file is confidential and can only be viewed by someone with authority to do so, for example, your attorney, a judge, or the claims examiner assigned to your case. Form OC 110a is an authorization by the injured worker to get access to his or her file. Some examples of those who might need this form are an attorney who is looking into your case, a healthcare provider who wants to review medical records or an insurance company looking into prior claims. The form must be completely filled out and must contain the original signature of the injured worker. The injured worker should be very careful about who gets this form, because the file contains a great deal of confidential and sensitive information. Never sign a blank, incomplete or undated Form OC 110A.

Form RFA 1-W

This form is used by the injured worker to request a hearing before the New York State Workers’ Compensation Board and it is fairly easy to fill out. Although it can be used for almost any situation which requires a hearing, the most common reasons for using this form are If weekly payments have been stopped or reduced or if the insurance company won’t pay for medical treatment. This form can be filed by electronically (online), by fax, by mail or in person. As with Form C-3, always keep a copy.

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