Db 450 Form – Fill Out and Use This PDF

NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY

1.Use this form if you become sick or disabled while employed or if you become sick or disabled within four (4)weeks after termination of employment. Use claim form DB-300 if you become sick or disabled after having been unemployed more than four (4) weeks.

2.You must complete all items of Part A - The "CLAIMANT'S STATEMENT". Be accurate. Check all dates.

3.Be Sure to date and sign your claim (see item 12). If you can not sign this form, yor representative may sign it in your behalf. In that event, the name, address and representative's relationship to you should be noted under the signature.

4.Do Not Mail this Claim unless your Health Care Provider Complete's and Signs Part B - The "HEALTH CARE PROVIDER'S STATEMENT".

5.Your completed claim should be mailed WITHIN 30 DAYS after you become sick or disabled, to your last employer or your last employer's insurance company.

6.Make a copy of this completed form for your records before you submit it.

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.

CLAIM SIGNED ON:

If signed by other than claimant, PRINT below: name, address, and relationship of representtive.

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, www.wcb.state.ny.us. It can be found under the heading Common Forms Online. Mail the completed authorization form or letter to the address given below.

After parts A, B, & C on page 1 and 2 are completed, Mail to: NYSIF Disability Benefits Claims, 15 Computer Drive West, Albany, NY 12205-1690

NOTICE OF PROOF OF CLAIM FOR DISABILITY BENEFITS - IMPORTANT: Use this form only when the claimant becomes sick or disable 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 is caused by or arising in connection with pregnancy, enter the estimated delivery date under "Remarks."

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 QUILTY OF A CRIME AND SUBJECT TO SUBSTANCIAL FINES AND IMPRISONMENT.

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

3.Employee's Address:

DB-450(1/05) After Parts A, B, & C are COMPLETED, Mail to: NYSIF Disability Benefits Claims, 15 Computer Drive West, Albany, NY 12205-1690