Impartial Specialists Report Of Medical Records Review {MR-4}

MR-4 - IMPARTIAL SPECIALIST'S REPORT OF MEDICAL RECORDS REVIEW. This form is used by the State of New York Workers' Compensation Board when conducting a review of medical records for a workers' compensation claim. The form is specifically used for procedures that require pre-authorization under the Medical Treatment Guidelines. The form includes information such as the Workers' Compensation Board case number, carrier case number (if known), date of injury, injured person's social security number, date of review, injured person's name and address, employer information, insurance carrier information, and details about the treatment/procedure requested. The Impartial Specialist completes the form by providing the results of the records review, certifying the report as a truthful representation of their professional opinion, and signing it. The form also includes information regarding the disclosure of Workers' Compensation Board records and HIPAA notice regarding the disclosure of health information. Contact information for the Workers' Compensation Board is provided at the bottom of the form. www.FormsWorkflow.com