Db-300 Form - Notice And Proof Of Claim For Disability Benefits By Unemployed Claimant Page 2

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PART B - HEALTH CARE PROVIDER'S STATEMENT

(Please Print or Type)

THE HEALTH CARE PROVIDER'S STATEMENT MUST BE FILLED IN COMPLETELY. THE ATTENDING HEALTH CARE PROVIDER SHALL COMPLETE AND MAIL SUCH

FORM TO THE WORKERS' COMPENSATION BOARD (SEE ADDRESS BELOW), OR RETURN IT TO THE CLAIMANT, WITHIN SEVEN (7) DAYS OF RECEIPT OF THIS

For item 7-d, give approximate date. Make some estimate. If disability is caused by or arising in connection with pregnancy, enter

FORM.

estimated delivery date under "Remarks."

INCOMPLETE ANSWERS MAY DELAY PAYMENT OF BENEFITS.

1. Claimant's Name.....................................................................................................................................2. Date of Birth.................3. Sex.................

First

Middle Initial

Last

4. Diagnosis/Analysis:......................................................................................................................................................................................................

a. Claimant's symptoms:.............................................................................................................................................................................................

.................................................................................................................................................................................................................................

b. Objective findings:....................................................................................................................................................................................................

5. Claimant hospitalized?

Yes

From...............................................To..................................................

6. Operation indicated?

Yes

a. Type..........................................b. Date...........................................

ENTER DATES FOR THE FOLLOWING

MONTH

DAY

YEAR

a. Date of your first treatment for this disability

b. Date of your most recent treatment for this disability

c. Date Claimant was unable to work because of this disability

d. Date Claimant will again be able to perform work

(Even if considerable question

exists, estimate date. Avoid use of terms such as unknown or undetermined.)

8. In your opinion, is this disability the result of injury arising out of and in the course of employment or occupational disease?

Yes

No If "Yes", has Form C-4 been filed with the Board?

Yes

Remarks:..........................................................................................................................................................................................................

Licensed or

License

9. I affirm that I am a..............................................................................Certified in the State of........................................No.:...............................

(Physician, Chiropractor, Dentist, Nurse-Midwife, Podiatrist or Psychologist)

Health Care Provider's Printed Name ..........................................................................Signature.......................................................................

Office

Date

Address.........................................................................................................................Tel No......................................Signed...........................

Number

Street

City/town

State

Zip

CLAIMANT: READ THESE INSTRUCTIONS CAREFULLY - ANSWER ALL QUESTIONS

1. MAKE SURE YOU FILE THE CORRECT CLAIM FORM. This is the correct claim form to use if you become sick or disabled

more than four (4) weeks AFTER you last worked.

2. COMPLETED CLAIM FOR DISABILITY BENEFITS. You complete and sign, Part A - Claimant's Statement. (If you are not able to sign

the Claimant's Statement, your representative may sign on your behalf. Place for signing is indicated by

on reverse side. Your

Health Care Provider completes and signs Part B - Health Care Provider's Statement.

3. FILE YOUR CLAIM FOR DISABILITY BENEFITS PROMPTLY. Your completed claim should be filed (mailed) not later than thirty (30)

days after you become sick or disabled. If it is being filed late (more than 30 days after your disability began) attach a statement

explaining why you could not file this claim earlier. Make a photocopy of this completed form for your records before you submit it.

Mail this form to:

Workers' Compensation Board

Disability Benefits Bureau

100 Broadway - Menands

Albany, NY, 12241-0005

Notification Pursuant to the New York Personal Privacy Protection Law (Public Officers Law Article 6-A) and the Federal Privacy Act of 1974 (5 U.S.C. Sec. 552a).

The Workers’ Compensation Board’s (“Board”) authority to request personal information from claimants is derived from Sections 20 and 142 of the Workers’ Compensation Law.

This information is collected to assist the Board in processing claims in an efficient manner and to help it maintain accurate claim records.

The Board is strongly committed to protecting the confidentiality of all personal information that it collects. Such information will be disclosed within the agency only to Board

personnel and agents in furtherance of their official duties. Personal information will be disclosed outside the agency only in accordance with applicable state and federal law.

The Board’s Director of Operations, located at 100 Broadway, Menands, New York 12241 (518-474-6674), is primarily responsible for the maintenance of agency records

containing personal claimant information.

Failure to provide the information requested on this form will not result in the denial of your claim, but may delay the processing of your claim. The voluntary release of your

social security number enables the Board to ensure that information is associated with, and quick action is taken on, your claim.

HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with

the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.

Disclosure of Information: The Board will not disclose any information about your case to any unauthorized party without your consent. If you choose to have such

information disclosed to an unauthorized party, you must file with the Board an original signed Form OC-110A, Claimant's Authorization to Disclose Workers'

Compensation Records, or an original signed, notarized authorization letter. You may telephone your local WCB office to have Form OC-110A sent to you, or you

may download it from our web page, It can be found under the heading Common Forms Online. Mail the completed authorization form or

letter to the address given on the front of this form.

SI TIENE DUDAS RELACIONADAS CON LA RECLAMACION DE BENEFICIOS

IF YOU HAVE ANY QUESTIONS ABOUT CLAIMING DISABILITY BENEFITS,

POR INCAPACIDAD, COMUNIQUESE CON LA OFICINA MAS CERCANA DE LA

CONTACT THE NEAREST OFFICE OF THE NYS WORKERS' COMPENSATION

JUNTA DE COMPENSACION OBRERA DE NUEVA YORK, O ESCRIBA A:

BOARD, OR WRITE TO: WORKERS' COMPENSATION BOARD, DISABILITY

WORKERS' COMPENSATION BOARD, DISABILITY BENEFITS BUREAU,100

BENEFITS BUREAU, 100 BROADWAY-MENANDS, ALBANY, NY 12241-0005.

BROADWAY- MENANDS, ALBANY. NY 12241-0005.

DB-300 (2-04) Reverse