Form Db450 - Notice And Proof Of Claim For Disability Benefits Page 2
ADVERTISEMENT
1
2NOTICE OF PROOF OF CLAIM FOR DISABILITY BENEFITS -
IMPORTANT: Use this form only when the claimant becomes sick or disabled
while employed or becomes sick or disabled within four(4) weeks after termination of employment. Otherwise use the green claim form DB-300.
Part B - Health Care Provider's Statement (Please Print or Type)
- The Health Care Provider's Statement must be filled in completely and the
Form mailed to the Insurance Carrier or Self-Insured employer, or returned to the claimant within SEVEN DAYS of the receipt of the Form. For item 7d, give the
approximate date. Make some estimate.
2.
3. Sex
1.
Date of Birth
Claimant's Name:
First
Middle
Last
Male
Female
4. Diagnosis / Analysis:
Diagnosis Code:
a. Claimant's Symptoms:
b. Objective Findings:
c.
If Disability is pregnancy related, enter ESTIMATED DELIVERY DATE .
5. Claimant Hospitalized?
Yes
No
Date from:
to
6. Operation indicated?
Yes
No
a. Type
b. Date
Month
Day
Year
7. Enter Dates for the following:
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 be able to perform usual work**………….................................…..
**
**Even if considerable question exists, ESTIMATE DATE . Avoid the use of terms such as unknown or undetermined.
Yes
No
8.
In your opinion is this Disability the result of injury arising out of the course of employment or occupational disease?
a. If yes, has Form C-4 been filed with the Workers' Compensation Board?
Yes
No
Remarks:
License Number:
I affirm that
Licensed in the State of:
Chiropractor
Physician
Psychologist
I am a:
Dentist
Podiatrist
Nurse-Midwife
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF
INSURER ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
Health Care Provider 's Signature
Date:
Health Care Provider's Name (Please Print)
Phone No.
Office Address:
Number
Street
Apt/Suite
City/Town
State
Zip Code
HIPPA NOTICE - In order to adjudicate a workers' compensation claim, WCL 13-8(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 184.512 these legally required medical reports are exempt from HIPPA's restrictions on disclosure of health information.
Part C - EMPLOYER'S STATEMENT
1.
2. Soc.Sec. No:
Employee's Name:
3.
Employee's Address:
Number
Street
City / Town
State
Zip Code
Apartment Number
4.
5.
Date of Hire:
6.
Status:
Employee's Occupation:
Full Time
Part Time
7.
Is the Claimant an:
Owner
Officer
Partner
Employee
High School Student
Indicate the employee's normal work schedule:
8.
Mon
Tues
Wed
Thur
Fri
Sat
Sun
If the employee is no longer in your employ, explain why:
9.
Quit?
Discharged?
Labor Dispute?
Lack of Work?
If Quit or Discharged explain why
Do you expect to rehire him/her?
Yes
No
10.
Date Employee last worked:
Weekly Wages 8 Weeks prior to Disability
(include value of Board, Lodging, and Tips if any)
11.
Date Employee's Wages Ceased:
No. of Days
Week Ending
12.
Date Employee Returned to Work:
GROSS WEEKLY WAGES
Worked
Day
Year
Month
13.
Are Wages being Continued during Disability? …………........
Yes
No
1.
14.
If YES , are you requesting reimbursement?.....……………........
Yes
No
2.
15.
Is Employee receiving or claiming Unemployment Ins? …….......
Yes
No
3.
Is Employee receiving or claiming Workers' Comp. Ins? ….........
16.
Yes
No
4.
17.
Did this Disability occur as a result of employment? ………….....
Yes
No
5.
Is Employee in a Union providing monetary Disability Benefits?..
18.
Yes
No
6.
19.
Are you aware of other employment claimant may have?............
Yes
No
7.
20.
Did Employee receive PAID SICK TIME during disability?........
Yes
No
8.
If YES, provide dates of paid sick time: From:
To:
TOTAL
SSLICNY Phone:
21.
Has employee made a claim for Disability Benefits in the past 52 weeks?
Yes
No
800-477-0087 or 585-398-2340
22.
TAXABLE PERCENTAGE__________%
DISABILITY POLICY NUMBER:
EMPLOYER INFORMATION:
Date:
Employer NAME:
Phone No.
Fax No.
E-mail:
ADDRESS:
Print name:
SIGNATURE:
Title:
After Parts A, B, & C are COMPLETED, Do one of the following:
Mail to: SSLICNY DBL Claims, P.O. Box 25339 Farmington, NY 14425 or
Fax to: 585-398-2854 or E-mail to:
DB450 (09/12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal