New York State Workers' Compensation Board Forms

This Form is used for authorizing the disclosure of health information in accordance with HIPAA regulations in New York.

This form is used for recording the percentage of hearing loss in the state of New York.

This form is used for obtaining a self-insurers' representative's bond in the state of New York.

This form is used for doctors in New York to report on the progress of their patients.

This form is used for submitting an initial application to obtain a license to legally represent a claimant in New York.

This form is used for resolving unresolved issues during expedited hearings in New York.

This document is used for recording agreed-upon findings and awards in a proposed conciliation decision for represented claimants in the state of New York.

This form is used for carriers or self-insured employers in New York to object to a request made by an attending doctor for medical authorization determination.

This form is used for attorneys or representatives to certify Form C-3 or Notice of Controversy in New York.

This Form is used for carriers in New York to report on rehabilitation efforts.

This Form is used for Attending Doctors in New York to request a determination for medical authorization.

This Form is used for filing a claim for compensation in a death case in New York for Chinese speakers.

This Form is used for filing a claim for compensation in a death case in New York, specifically for individuals who speak Haitian Creole.

This Form is used for filing a claim for compensation in a death case in New York. The form is available in Korean.

This form is used for the impartial specialist to report and review medical records in New York.

This form is used for notifying the election of a municipal corporation or other political subdivision in New York to bring executive officers under the coverage of Workers' Compensation Law (WCL).

This Form is used for notifying the New York State Workers' Compensation Board of the election of a partnership, limited liability partnership, limited liability company, or sole proprietorship to bring partners, members, or self-employed persons under the coverage of the New York State Workers' Compensation Law.

This form is used for revoking the election of a municipality or political subdivision in New York to bring executive officers under Workers' Compensation Law coverage.

This document is used for notifying the election of a not-for-profit corporation or association to exclude an unsalaried executive officer from workers' compensation coverage according to Section 54, Subdivision 6 of the Workers' Compensation Law in New York.

This form is used for revoking the election of a not-for-profit corporation or unincorporated association in New York to exclude an unsalaried executive officer from coverage.

This form is used for employers in New York who want to elect to provide workers' compensation benefits to participants in a sheltered workshop.

This form is used for revoking the election to exclude the sole shareholder or two executive officers from compensation coverage in New York.

This form is used for applying to take the License Representative Exam in New York for the first time.

This document is used to notify the responsible political subdivision of an injury or death of a volunteer ambulance worker in New York.

This Form is used for reporting loss of wage earning capacity and vocational data in New York.

This type of document, VDF-1 Loss of Wage Earning Capacity Vocational Data Form, is used in New York to gather vocational data related to loss of wage earning capacity. The form is available in Chinese language.

This Form is used for reporting a loss of wage earning capacity and vocational data in New York for those who speak Haitian Creole.

This form is used for reporting and collecting data related to the loss of wage earning capacity in New York. It is specifically designed for Korean-speaking individuals.

This form is used to notify a political subdivision in New York about an injury or death of a volunteer firefighter.

This form is used for biannual recertification of entitlement to benefits in the state of New York. It is used to verify and update information regarding eligibility for benefits.

This document is used for electronically attaching additional information or files to a submission or application in the state of New York.

This form is used to notify the chair of a health provider's and insurer's decision to withdraw their request for arbitration in New York.

This form is used for reporting an independent medical examination in response to a request for information in New York.