Nys Form Nf-3 - Verification Of Treatment By Attending Physician Or Other Provider Of Health Service
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4NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
(This form is not for verification of hospital treatment )
NAME AND ADDRESS OF INSURER OR SELF-
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER*
INSURER’S CLAIMS REPRESENTATIVE*
DATE
POLICYHOLDER
POLICY NUMBER
DATE OF ACCIDENT
CLAIM NUMBER
PROVIDER'S NAME AND ADDRESS*
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE, THIS COMPLETED
FORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSIBLE BUT NO LATER
THAN 45 DAYS OR 180 DAYS AFTER THE TREATMENT DATE, DEPENDING UPON THE POLICY
ENDORSEMENT IN EFFECT AT THE TIME OF THE ACCIDENT. IF YOU ARE UNSURE OF THE APPLICABLE
TIME REQUIREMENT, KINDLY CONTACT THE CLAIMS REPRESENTATIVE TO DETERMINE WHICH
DEADLINE IS APPLICABLE TO THIS CLAIM.
IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY
CHANGES FROM THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES.
1. PATIENT'S NAME AND ADDRESS
2. DATE OF BIRTH
3. SEX
4. OCCUPATION (IF KNOWN)
5. DIAGNOSIS AND CONCURRENT CONDITIONS
6. WHEN DID SYMPTOMS FIRST APPEAR?
7. WHEN DID PATIENT FIRST CONSULT YOU FOR THIS
DATE:
CONDITION?
DATE:
8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
YES
NO
IF YES, state when and describe:
9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT?
YES
NO
IF "NO", explain:
10. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT’S EMPLOYMENT?
YES
NO
11. WILL INJURY RESULT IN SIGNIFICANT DISFIGUREMENT OR PERMANENT DISABILITY?
YES
NO
NOT DETERMINABLE AT THIS TIME
IF "YES", describe:
12. PATIENT WAS DISABLED (UNABLE TO WORK)
13. IF STILL DISABLED THE PATIENT SHOULD BE
ABLE TO RETURN TO WORK ON:
FROM:
THROUGH:
(DATE)
CONTINUE ON PAGE 2
NYS FORM NF-3 (Rev 1/2004)
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