Form Db-450 - Notice And Proof Of Claim For Disability Benefits Page 2
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2Fax: 610-807-2953 or email:
NOTICE 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. If the Disability was caused by or arose in connection with pregnancy, enter the estimated delivery date under “Remarks.”
2. Date of Birth
1. Claimant’s Name:
3. Sex
Male
(First, Middle, Last)
Female
4. Diagnosis/Analysis: _______________________________________________________ ICD _________________________________________
a. Claimant’s Symptoms: _______________________________________________________________________________________________
b. Objective Findings/Treatment Plan: _____________________________________________________________________________________
c. If Disability is pregnancy related, enter DELIVERY DATE _____________________
Estimated
Actual
Vaginal
C-Section
5. Claimant Hospitalized?
YES
NO
Date From: _____________ To _______________
6. Operation Indicated?
YES
NO
a. Type : _____________ b. Date _______________ c. CPT ___________________
7. Enter Dates for the Following:
Mo.
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 be able to perform usual 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 the course of employment or occupational disease?
Yes
No
a. If yes, has Form C-4 been filed with the Workers Compensation Board?
Yes
No
Remarks:
__________________________________________________________________________________________
Licensed in the State of:
Licensed #:
I affirm that
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 #:
Office Address
(Number, street, Apt./Suite, City/Town, State, Zip Code)
HIPAA NOTICE - In order to adjudicate a worker’s compensation claim, WCL 13-8 (4) (a) and 12 NYCRR 325-1.3 require health care providers to
regularly file medical reports or treatment with the Board and the carrier or employer. Pursuant to 45 CFR 184.512 these legally required medical
reports are exempt from HIPAA’S restrictions on disclosure of health information.
Part C – EMPLOYER’S STATEMENT
1. Employee’s Name
2. Social Security #:
3. Employee’s Address
Apt. #.
City
State
Zip
4. Employee’s occupation
5. Date of Hire
6. Status:
Full Time
Part Time
7. Is the Claimant an:
Owner
Officer
Partner
Employee
High School Student
8. Indicate the Employee’s normal work schedule:
Mon
Tue
Wed
Thur
Fri
Sat
Sun
9. If the employee is no longer employed, explain why:
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
11. Date Employee’s Wages Ceased: ____________________________
(include value of Board, Lodging and Trips, if any)
12. Date Employee Returned to Work: ____________________________
Week Ending
No. of Days
GROSS WEEKLY
13. Are Wages being Continued during Disability?
Yes
No
Month Day Year
Worked
WAGES
1.
14. If YES, are you requesting reimbursement?
Yes
No
2.
15. Is Employee receiving or claiming Unemployment Ins.?
Yes
No
3.
16. Is Employee receiving or claiming Workers’ Comp. Ins.?
Yes
No
4.
17. Did this Disability occur as a result of employment?
Yes
No
5.
18. Is employee in a Union providing Disability Benefits?
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
EMPLOYER INFORMATION
Policy #:
Tax ID #:
Date:
Employer Name:
Division #:
Phone #:
Fax #:
Address:
E-mail:
Signature:
Print Name:
Title:
DB-450 (Rev. 5/14)
After Parts A, B, & C are completed, Mail to: Guardian – State Disability Claims – P.O. Box 14332, Lexington, KY 40512 or
Fax: 610-807-2953 or email: Secure E-mail: , click Secure Channel, select
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