What makes an MG-2 form complete?

All Board forms should be completely filled out with all available information. Certain information is essential to the Board's internal procedures. Without that essential information, the Board cannot process the form. In order for the Board to take action on an MG-2 form, the Board requires that the following fields be completed.

Section A:
(1) Patient's name, and
(2) Insurance Carrier's Name & Address.
Please note that the Insurance Carrier's or TPA's name and address must match the information the Board has on file.
Section B:
(1) Individual Provider's WCB Authorization Number for all providers authorized by the New York State Workers' Compensation Board
Section C:
(1) Date Variance Request Submitted and Method of Transmission,
(2) Guideline Reference for the body part followed by the 2 to 4 character corresponding reference in the Medical Treatment Guidelines or followed by the four letters N-O-N-E if there is no listed procedure,
(3) Approval Requested For requires a written description of the treatment requested,
(4) Statement of Medical Necessity requires a description directly on the form and if there is a supporting medical report in the Board's case file, enter the date of service or if there is no supporting medical report in the case file, attach a medical report and enter "See attached medical report" on the form;
(5) A check box selected for how the carrier was contacted. Please note if you listed your fax number at the top of the form, do not select the second check box; and
(6) the Provider's signature or stamp. Please note that initials next to the signature or stamp are not acceptable.
All other information that is requested on the form should be filled in if available.

Example of a Properly Completed MG-2 Form