Nys Form Nf-3 - Verification Of Treatment By Attending Physician Or Other Provider Of Health Service Page 2
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4VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
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14. WILL THE PATIENT REQUIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE
INJURIES SUSTAINED IN THIS ACCIDENT?
YES
NO
IF YES, describe your recommendation below:
15. REPORT OF SERVICES RENDERED -- ATTACH ADDITIONAL SHEETS IF NECESSARY
DATE OF
PLACE OF SERVICE
DESCRIPTION OF TREATMENT
FEE SCHEDULE
CHARGES
SERVICE
INCLUDING ZIP CODE
OR HEALTH SERVICE RENDERED
TREATMENT CODE
TOTAL CHARGES TO DATE$
16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOWING:
TREATING PROVIDER'S
LICENSE OR
BUSINESS RELATIONSHIP
TITLE
NAME
CERTIFICATION NO.
CHECK APPLICABLE BOX
EMPLOYEE
INDEPENDENT
OTHER (SPECIFY)
CONTRACTOR
17. IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS
UNDER AN ASSUMED NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF
ALL OWNERS (Provide an additional attachment if necessary).
18. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION?
YES
NO
19. ESTIMATED DURATION OF FUTURE TREATMENT
PATIENT: Your health provider may agree to accept payment for health services performed directly from your insurer (Authorization to
Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on
the part of the health provider and must be signed by both patient and health provider. You may use the optional authorization language
provided below, by checking off the designated spot in item 20 of this form.
20.
(IF YOU HAVE CHOSEN TO AUTHORIZE THE DIRECT PAYMENT OF BENEFITS BY CHECKING THIS OPTION, YOU MAY NOT
ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN #21)
AUTHORIZATION TO PAY BENEFITS:
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES
DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-FAULT PROVISION) OF THE INSURANCE LAW.
PRINT NAME
SIGNED
PATIENT
PATIENT
DATE
CONTINUE ON PAGE 3
NYS FORM NF-3 (Rev 1/2004)
Page 2 of 3
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