HOW TO USE THE NEW YORK “C4” FORM

 

 

This form requires a “mix” of both billing information and a “mini” narrative format.  If we setup some User Defined fields ahead of time, this form becomes fairly easy to use.

 

User Defined Fields

Open the System Registry Entry.  Using the “pull down” arrow, find “User Definable Fields for Patient Master Files”.  We suggest that you make the following entries:

CODE             NAME/DESCRIPTION

USER 6           Type of Work          (Use this to list any limitations or work capacity)

USER 10         Past Medical History

 

Using the “pull down” arrow, find “User Definable Fields for Patient Claim Files”.  We suggest that you make the following entries:

 

CODE             NAME/DESCRIPTION

USER 8           Disability=Total/Partial  (Type one word or the other)

USER 9           If disability, Describe  (i.e. Permanent partial disability)

 

We will now use these fields and the existing program fields to fill in the necessary areas of the C4 form.

 

C4 Fields

See the sample form attached.  The “X”’s seen on this sample are set to fill in automatically. The following numbers correspond to this layout and list the field that will need to be filled to answer this question.

 

            Table                           Tab                                          Field Name

1)                  Patient Claim   1st Responsible                        Insured’s ID #

2)                  Patient Claim  1st Responsible                        Insurance Plan Name

3)                  Patient Claim               General                                    Injury Date

4)                  Patient Claim               General                                    Place of Injury

5)                  Patient Entry               Patient Information                 SSN

6)                  Patient Entry               Patient Information                 Patient First & Last Name

6A)      Patient Entry               Patient Information                 Patient Address/City/St/Zip

7)         Patient Claim               Relations & Contacts  Employer Name

7A)      Patient Claim               Relations & Contacts  Employer Add/City/St/Zip

8)         Patient Claim               1st Responsible                        Carrier

8A)      Carrier Information                                                     Carrier Address/City/St/Zip

9)         Patient Entry               Additional Information           Primary Doctor

9A)      Clinic Information                                                       Clinic Address/City/St/Zip

10)       Patient Entry               General                                    Patient Phone Number

11)       Patient Entry               General                                    Birthdate

*12)     This field is entered directly onto the C4 Form

Table                           Tab                                          Field Name

 

13)       Patient Claim               General                                    Injury Description

14)       Patient Entry               User Defined                           Past Medical History

15)       This Bill                       Automatically pulls first and last service date on bill

16)       Patient Claim               General                                    Claim Originated

17)       Patient Claim               User Defined                           Miscellaneous 1

*18)     This field is entered directly onto the C4 Form

19)       Patient Claim               User Defined                           If Disability, Describe

If there is information typed into the above field, an “X” will be placed in the YES.  If it is EMPTY, and “X” will be placed in the NO.

20)       Patient Claim               User Defined                           If Disability, Describe

21)       Patient Claim               General                                    Unable to Work From

22)       Patient Claim               General                                    Unable to Work From

If there is information typed into the above field, an “X” will be placed in the NO.  If it is EMPTY, and “X” will be placed in the YES.

23)       Patient Entry               User Defined                           Type of Work

If there is information typed into the above field, an “X” will be placed in the NO.  If it is EMPTY, and “X” will be placed in the YES.

24)       Patient Claim               User Defined                           Disability=Total/Partial

If “Total” is typed into the above field, an “X” will be placed in TOTAL.  If “Partial” is typed into the above field, an “X” will be placed in PARTIAL.

25)       Patient Entry               User Defined                           Type of Work

If there is information typed into the above field, an “X” will be placed in the NO.  If it is EMPTY, and “X” will be placed in the YES.

26)       Patient Entry               User Defined                           Type of Work

27)       Patient Claim               General                                    Patient’s Condition

Related to Employment

If the above field is checked (4), an “X” will be placed in YES.  If it is not checked, an “X” will be placed in NO.

28)       Patient Claim               Diagnosis                                 1-4 Diagnosis in file

29)       This Bill                       Automatically fills in Dates of Service for this bill

30)       Doctor Information     Doctor Detail                          Federal ID #

31)       Patient Entry               General                                    Patient#/Code

32)       This Bill                       Automatically Totals the Charges on this bill

*33)     This field is entered directly onto the C4 Form

*34)     This field is entered directly onto the C4 Form

35)       This Bill                       Automatically fills in the Bill Date for this Bill

36)       Doctor Information     Doctor Detail                          Doctor First & Last Name

                                                                                                Clinic Address/City/St/Zip

37)       Clinic Information                                                       Clinic Name

                                                                                                Clinic Address/City/St/Zip

 

C4 Fields – Entered Directly onto the Form

The following entries need to be entered directly onto the C4 form.  To edit these fields go to Reports Menu.  Arrow down to the NY C4 form and then click on Layout.  You will see a screen with a lot of “boxes”.  This is your form layout.

 

*12)     This is currently set to fill in the following information  “TUESDAY”   and   “AM”.    To change these entries double click on this field to bring up the Expression Format.  Then click on the button to the right of this field ([…]) to expand this box so that you can see the entire expression.  Highlight the TUESDAY and replace with the day of the week that is specific to your office.

 

*18)     This is currently set to fill in the following information “Chiro Adjustments as needed”. To change these entries double click on this field to bring up the Expression Format.  Then click on the button to the right of this field ([…]) to expand this box so that you can see the entire expression.  Highlight the “Chiro Adjustments as needed” and replace with the day of the week that is specific to your office.

 

*33)     This field is currently set to fill in the following information “XX”. To change these entries double click on this field to bring up the Expression Format.  Then click on the button to the right of this field ([…]) to expand this box so that you can see the entire expression.  Highlight the “XX” and replace with the day of the week that is specific to your office.

 

*34)     This field is currently set to fill in the following information “XX”. To change these entries double click on this field to bring up the Expression Format.  Then click on the button to the right of this field ([…]) to expand this box so that you can see the entire expression.  Highlight the “XX” and replace with the day of the week that is specific to your office.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sample – C4 Form – User Entries #12 (Day and AM/PM)  and #18

 

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sample – C4 Form – User Entries #33 and #34