Form guide · Medical Narrative Report Template

How to complete the NY workers' comp medical narrative template

New York workers' compensation medical reports now go on the CMS-1500 with a narrative report. The Board's Medical Narrative Report Template is the cover page for that narrative. This guide walks through it in the template's order.

Form: Medical Narrative Report Template for CMS-1500 (New York workers' compensation)
Issued by: New York State Workers' Compensation Board
Revision: Current template (replaces the C-4 family, retired July 1, 2022)
Checked against the source: November 5, 2026

What it is and when it is used

On July 1, 2022 the New York Workers' Compensation Board replaced the C-4 family of medical report forms with the CMS-1500 claim form plus a narrative report. A CMS-1500 needs the detailed narrative attached to count as a valid submission.

The Board publishes a one-page template to sit on top of the narrative. It carries the case identifiers and the three items every report must address. The template's instructions say it can be used for workers' compensation, volunteer firefighters' and volunteer ambulance workers' benefit cases.

The instructions also say you may use your own narrative report instead of the template, as long as it covers the same three items.

Who completes which part

Part	Completed by	What it covers
Template and narrative	Treating provider	The identifiers, the three required items, the attached narrative, and the signature.
CMS-1500	Provider or billing staff	All the billing information on the CMS-1500 itself. The template must be signed by the provider who signs field 31 of the CMS-1500.

The provider's part, section by section

The template's instructions warn that a report may be found legally defective when the narrative does not contain the three required items in the format the Board prescribes.

Header: case and provider identifiers

The patient's name and date of birth, the WCB case number if known, the insurer's case number, the date of injury or onset of illness, your name, NPI number, WCB authorization number and WCB rating code, and the dates of service.

1. Work status

Has the patient missed work because of the injury or illness, and from what date? Are they working now, and since when, on limited or full duty? If not working, can they return to their usual work? List any work limitations, with how much and for how long.

The instructions note that physical therapists, occupational therapists and acupuncturists may not give part of this item.

2. Causal relationship

Is the incident the patient describes the competent medical cause of the injury or illness? Are the patient's complaints consistent with the history they give? Is that history consistent with your objective findings, or is that not applicable at this visit?

The instructions note that an opinion on causation from a physical therapist, occupational therapist, acupuncturist or physician assistant is not considered evidence of it.

3. Temporary impairment percentage

The percentage of temporary impairment, from 0 to 100 percent, with your findings and how you reached the number.

The instructions note that a physician assistant's opinion is not evidence of initial disability, and that physical therapists, occupational therapists and acupuncturists may not give a percentage.

The attached narrative

Attach the narrative report with examination findings. The instructions say it should include the history of the injury or illness, objective findings from your evaluation, the plan of care, and your diagnoses or assessment.

Signature

Sign and date the template. The signer must be the provider who signs field 31 of the CMS-1500, and the template must carry that provider's authorization number, rating code and NPI.

Deadlines the form states

Initial report: the template and narrative within 48 hours after you first treat the patient.
Progress reports: within 15 days after the initial report, then one for each follow-up visit when medically necessary, no more than 90 days apart.

Where it goes

The instructions say every report is filed with the Workers' Compensation Board and the workers' compensation carrier or self-insured employer, and with the patient's attorney or licensed representative if they have one. If the patient has no representative, they get a copy.

The Board's CMS-1500 pages explain how the bill and its attachments are submitted.

Official source

Current template (replaces the C-4 family, retired July 1, 2022). Checked against the issuer's copy on November 5, 2026. This guide paraphrases the form's own instructions; the form and New York State Workers' Compensation Board are the authority.

How Scribeable fills it

Scribeable fills the Board's official template from your visit note, and writes the narrative from the same note: the history of the injury or illness, the objective findings, the plan of care and the assessment.

It answers work status, causal relationship and temporary impairment only from what the note states. If the note does not state an impairment percentage or an opinion on cause, that item stays blank for you. Case numbers and Board identifiers the note does not carry stay blank too, and your signature and the date are yours to add.

Each filled answer shows the sentence in the note it came from, so you can check it before you sign.

Sentences in the note that name HIV, substance use or mental health are left out of the narrative pages.

You review every field, then download or print the template and narrative, sign, and attach them to the CMS-1500.

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