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C4 Forms and
Workers' Compensation Billing


     C4 forms are required when billing for medical services related to workers' compensation when a patient was injured on the job.  Workers compensation insurance will pay for all sorts of medical benefits.

     Many practice management systems come with these forms as a standard insurance form listed in the insurance form menu of the program. That is the easiest way to submit them. You actually print the claim on white paper, and the program not only prints up the charges and other information, but actually creates the form too.

     If your practice management system does not have the form available, you can usually get a blank form online through your state's website.  Some companies also sell blank forms.

     Once you have a blank form, you can either type the information in, or if your software has the capabilities, you can program your software to fill in the boxes on the form.

     In any case, you will need to submit a copy directly to the workers' compensation carrier, and the state workers' compensation board as well.  The board needs a copy of every workers comp claim filed.  Mileage for the injured patient is calculated from the comp boards records.

     Some of the information contained on the C4form is:

  • Patient's demographics
  • Workers' comp carrier name & id #'s, including WCB #
  • Employer information
  • Location, Date & Description of how injury occurred
  • Information on evidence of pre-existing condition
  • Patient's current working status
  • If patient is disabled from regular duties
  • Is disability total or partial
  • Is injury going to result in permanent restriction
  • Information on treatment being rendered
  • Diagnosis, date of service, procedures, and charges
  • Provider's billing information

     It is extremely important that all boxes on the C4form are completed accurately.  The information on these forms is used during any hearings for the injured party.  If the information is not completed, or is not accurate, it can adversely affect the outcome of the hearing.



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