Form Db450 - Notice And Proof Of Claim For Disability Benefits Page 3
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3PART 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 RETURN TO THE CLAIMANT WITHIN SEVEN (7) DAYS OF RECEIPT OF THIS FORM. For item 7-d, you must give estimated
date. If disability is caused by or arising in connection with pregnancy, enter estimated delivery date in item 9. INCOMPLETE ANSWERS MAY DELAY
PAYMENT OF BENEFITS.
1. Last Name:
First Name:
MI:
/
/
2. Gender:
Male
Female
3. Date of Birth:
4. Diagnosis/Analysis:
Diagnosis Code:
a. Claimant's symptoms:
b. Objective findings:
/
/
/
/
5. Claimant hospitalized?:
From:
To:
Yes
No
/
/
6. Operation indicated?:
Yes
No
a. Type
b. Date
7.
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.)
e. If pregnancy related, please check box and enter the date
estimated delivery date OR
actual delivery date
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
No
I certify that I am a:
Licensed or Certified in the State of
License Number
(Physician, Chiropractor, Dentist, Podiatrist, Psychologist, Nurse-Midwife)
Health Care Provider's Printed Name
Health Care Provider's Signature
Date
Health Care Provider's Address
Phone #
Part C - EMPLOYER'S STATEMENT
2. Soc. Sec. #:
1.
Employee’s Name:
3.
Employee’s Address:
Number
Street
Apartment Number
City / Town
State
Zip Code
4.
Employee’s Occupation:
5. Date of Hire:
6. Status:
Full Time
Part Time
7.
Is the Claimant an:
Employee
Owner
High School Student
7a. Date of Birth
Indicate the employee’s normal work schedule:
Mon
Tues
Wed
Thur
Fri
Sat
Sun
8.
If the employee is no longer in your employ, explain why:
Quit
Fired
Laid Off
Other (explain)
9.
10a. Do you expect to rehire him/her?
YES
NO
10.
Date Employee last worked:
11.
Date Employee returned to work:
Weekly Wages 8 Weeks prior to Last Day Worked Before Disability
(include value of Board, Lodging, and Tips if any)
YES
NO
12.
Are you paying wages or sick time: ................................................................
Week Ending
No. of Days
a.
If YES, time period paid:
GROSS WEEKLY WAGES
Month
Day
Year
Worked
YES
NO
Are you requesting reimbursement for this time period? ...............................
b.
1.
YES
NO
Is Employee receiving or claiming Unemployment Ins? ................................
13.
2.
YES
NO
14.
Is Employee receiving or claiming Workers’ Comp. Ins? ..............................
3.
YES
NO
15.
Did this Disability occur as a result of employment? .....................................
4.
YES
NO
16.
Is Employee in a Union proving MONETARY DISABILITY BENEFITS? .....
5.
YES
NO
17.
Are you aware of other employment claimant may have? ............................
6.
YES
NO
Has the employee received DBL or PFL benefits within the past 52 weeks?
18.
7.
19.
TAXABLE PERCENTAGE
%
8.
POLICY NUMBER:
TOTAL
EMPLOYER INFORMATION:
Employer Name:
Employer Address:
Phone:
Fax:
E-mail:
Print Name:
Sign:
Title:
Date:
SSLICNY Phone: 800-477-0087 or 585-398-2340
After Parts A, B, & C are COMPLETED, Do one of the following:
Mail to: SSLICNY, P.O. Box 25339 Farmington, NY 14425 or Fax to: 585-398-2854 or E-mail to:
DB-450 (9-17) Page 2 of 2
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