Fillable Form Db450 - Notice And Proof Of Claim For Disability Benefits printable pdf download

CLAIMANT: READ THESE INSTRUCTIONS CAREFULLY

PLEASE NOTE: Do not date and file this form prior to your first date of disability. In order for your claim to be

processed, Parts A B and C must be completed.

1. If you are using this form because you became disabled while employed or you became disabled within four (4)

weeks after termination of employment, your completed claim should be mailed within thirty (30) days to your

employer or your last employer's insurance carrier. You may find your employer's disability insurance carrier on

the Workers' Compensation Board's website using Employer Coverage Search.

2. If you are using this form because you became disabled after having been unemployed for more than four (4)

weeks, your completed claim should be mailed to: Workers' Compensation Board, Disability Benefits Bureau, 328

State Street, Schenectady, NY 12305. If you answered "Yes" to question 14.B.3, please complete and attach Form

DB-450.1.

If you have any questions about claiming disability benefits, you may contact the Board's Disability Benefits Bureau at

(800) 353-3092. Additional information may be obtained at the Board's website: , or you may write to the

Disability Benefits Bureau at the address listed above.

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. § 552a). The Workers' Compensation Board's (Board's) authority to request that

claimants provide personal information, including their social security number, is derived from the Board's investigatory

authority under Workers' Compensation Law (WCL) § 20, and its administrative authority under WCL § 142. This

information is collected to assist the Board in investigating and administering claims in the most expedient manner

possible and to help it maintain accurate claim records. Providing your social security number to the Board is voluntary.

There is no penalty for failure to provide your social security number on this form; it will not result in a denial of your claim

or a reduction in benefits. The Board will protect the confidentiality of all personal information in its possession, disclosing

it only in furtherance of its official duties and in accordance with applicable state and federal law

HIPAA NOTICE - In order to adjudicate a workers' compensation claim or disability benefits claim, WCL 13-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

insurance 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 website, . It can be found under Forms on the 'List of All Common

Workers' Compensation Board Forms' web page. Mail the completed authorization form to the address listed above.

An employer or insurer, or any employee, agent, or person acting on behalf of an employer or insurer, who KNOWINGLY

MAKES A FALSE STATEMENT OR REPRESENTATION as to a material fact in the course of reporting, investigation of,

or adjusting a claim for any benefit or payment under this chapter for the purpose of avoiding provision of such payment or

benefit SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.

Form Db450 - Notice And Proof Of Claim For Disability Benefits