Contact Information

First Name

Last Name

Phone

Email

Name of Hospital

Tax ID

Address One

Address Two

City

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Zip

County

Work Comp Board#

JCAHO Accredited? YesNo

Comments

If you are not currently authorized to treat workers’ compensation patients in NY, you can find the “Health Care Providers Application for Authorization” on the NYS WCB website at http://www.wcb.ny.gov/content/main/hcpp/hcpp.jsp