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C-4 Forms For Workers' Compensation Claims

When an employee has suffered an industrial injury in Nevada, one step the injured worker must take is to file their worker’s compensation claim by filling out a C-4 form.

The C-4 form will be filled out by the injured worker at their initial doctor/hospital visit. The injured worker will need to state how the accident happened, when the injured worker reported the accident to their supervisor, and what body parts were injured. Careful attention should be made in filling out the form, as the information must be accurate and correct. The C-4 form will be used by the insurer in their decision making process as to whether to accept or deny the workers compensation claim. For example, insurance adjusters look at whether the injured worker reported their injury timely to their supervisor. They also look at how the industrial accident happened and whether it meets the definition of accident under NRS 616A.030 and injury under NRS 616A.265.

The doctor will fill out the lower portion of the C-4 form. It will note if the doctor believes that the injury was job incurred, what is the diagnosis, is follow up treatment needed, and if the injured worker is able to return to full duty work, off of work, or if they were given work restrictions.

The injured worker should always receive a copy of the C-4 form when they leave the doctor’s office or hospital. This is their proof that they have filled out the C-4 form. The doctor is required to forward the completed C-4 form to the insurer. (NAC 616C.080). The insurer must now either accept or deny the claim within 30 days after they have been notified of the industrial accident. (NRS 616C.065).

To view an actual C-4 form, click here.

I hope that this has been helpful and informative. There are additional steps to filing a worker’s compensation claim so I encourage you to read my other blogs for more free, valuable information.

Joel A. Santos, Esq., is a Nevada worker’s compensation attorney. He is certified by the State Bar of Nevada as a Worker’s Compensation Expert and Specialist.

Copyright 2020 - Joel A. Santos, Esq.


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