Tip for C-4 / PR-2 (state-specific)

Ensure your doctor provides detailed, specific work restrictions — vague reports cause delays

Tip for C-4 / PR-2 (state-specific)

Ask your doctor for a copy of every report submitted to the carrier

Tip for C-4 / PR-2 (state-specific)

If the carrier disputes the doctor's findings, they may request an IME

Workers' CompensationhardDoctor signature required

Physician's Progress Report

C-4 / PR-2 (state-specific) · State Workers' Compensation Boards

Physician's initial and progress reports documenting diagnosis, treatment, work restrictions, and disability status. Form numbers vary by state (e.g., NY C-4, CA PR-2).

Form Details

Total fields: 50
Auto-fillable: 28 (56%)
Time without BeneFill: 35 minutes
Time with BeneFill: 10 minutes
Time saved: 25 minutes
Filled by: doctor
Frequency: as needed
State-specific: Yes — form may vary by state

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Where to Submit This Form

📠

Your treating physician submits to the workers' comp carrier

The doctor's office typically handles submission. Ensure your doctor knows this is a workers' comp case.

📬

Mail to the workers' comp insurance carrier's claims department

Filing Deadline

Initial report typically due within 5-10 days of first treatment. Progress reports are required at regular intervals (varies by state).

Required Attachments

📎 Treating physician's report with diagnosis, treatment plan, and work restrictions
📎 Objective medical findings (exam results, imaging, lab work)
📎 Work capacity assessment (what the patient can and cannot do)
📎 Expected duration of disability and treatment

Processing Time

The carrier should review and act on the report within 5-14 days. Treatment authorizations may follow.

What Happens Next

The insurance carrier will use the doctor's report to authorize treatment, adjust benefits, and determine work status. Regular progress reports keep benefits flowing.

Tips for This Form

✓ Ensure your doctor provides detailed, specific work restrictions — vague reports cause delays
✓ Ask your doctor for a copy of every report submitted to the carrier
✓ If the carrier disputes the doctor's findings, they may request an IME
✓ Consistent treatment and reporting strengthens your claim — gaps weaken it

More Workers' Compensation Forms

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Workers' Compensation Boards or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.