Form Db 450 Disability – Fill Out and Use This PDF

The DB-450 form is an essential document for New Yorkers to initiate a claim for disability benefits, ensuring they comply with the state's procedural requirements. This form serves as a formal notification and proof of claim, requiring detailed information from both the claimant and their healthcare provider to avoid any delays in processing. It is vital for individuals facing disabilities to accurately complete and submit this form promptly to support their claim for benefits.

To ensure your claim is processed efficiently, click the button below to get started on filling out your DB-450 Disability Form.

Get Form Now Download PDF

Form Db 450 Disability PDF Details

Understanding the complexities of navigating through disability claims can be daunting for many. The DB-450 form, called the New York State Notice and Proof of Claim for Disability Benefits, serves as a cornerstone for initiating a disability claim within the state. Designed to ensure that individuals who are temporarily unable to work due to a disability receive their rightful benefits, this form requires careful attention to detail. It is divided into two main parts: Part A, which must be filled out by the claimant, covers essential personal information, including the claimant's name, contact details, the nature of the disability, employment information before the disability occurred, and any other benefits received or claimed. Part B, on the other hand, requires a healthcare provider's input on the claimant's condition, including diagnosis, treatment dates, and an estimation of when the claimant might return to work. Key to the form's processing is the timely submission and completeness of the provided information, which includes accurate details of any additional employment, earnings, and union memberships, as well as a truthful declaration regarding the disability's impact on the claimant's ability to work. The instructions accompanying the form emphasize the significance of submitting the form within specified timeframes to ensure the claim is processed without unnecessary delays. This intricate process underscores the importance of understanding one's rights and responsibilities when facing a period of disability, making the DB-450 form an essential tool for accessing benefits designed to aid in such times.

Question	Answer
Form Name	Form Db 450 Disability
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	new york state short term disability form, db450, new york state disability form, nys disability form db 450

Form Preview Example

DB-450 1-20	New York State
	NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS

Read instructions on page 2 carefully to avoid a delay in processing. You must answer all questions in Part A and questions 1 through 3 in Part B. Health care providers must complete Part B on page 2.

PART A - CLAIMANT'S INFORMATION (Please Print or Type)

Last Name:

First Name:

MI:

Mailing Address (Street & Apt. #):

City:

State:

Zip:

3. Daytime Phone #:

Email Address:

4. Social Security #:

5. Date of Birth:

6. Gender:

Male

Female

7.Describe your disability (if injury, also state how, when and where it occurred):

8. Date you became disabled:

Did you work on that day?: Yes No

Have you recovered from this disability?:

Yes

If Yes, date you were able to return to work:

Have you since worked for wages or profit?:

Yes

No If Yes, list dates:

9.Name of last employer prior to disability. If more than one employer in previous eight (8) weeks, name all employers. Average Weekly Wage is based on all wages earned in last eight (8) weeks worked.

LAST EMPLOYER PRIOR TO DISABILITY			PERIOD OF EMPLOYMENT						Average Weekly Wage
LAST EMPLOYER PRIOR TO DISABILITY			PERIOD OF EMPLOYMENT						(Include Bonuses, Tips,
									Commissions, Reasonable
Firm or Trade Name	Address	Phone Number		First Day		Last Day Worked			Value of Board, Rent, etc.)
			Mo.	Day	Yr.	Mo.	Day	Yr.
OTHER EMPLOYER (during last eight (8) weeks)			PERIOD OF EMPLOYMENT						Average Weekly Wage
OTHER EMPLOYER (during last eight (8) weeks)			PERIOD OF EMPLOYMENT						(Include Bonuses, Tips,
									Commissions, Reasonable
Firm or Trade Name	Address	Phone Number		First Day		Last Day Worked			Value of Board, Rent, etc.)
			Mo.	Day	Yr.	Mo.	Day	Yr.
			Mo.	Day	Yr.	Mo.	Day	Yr.

10. My job is or was:		11. Union Member:		Yes	No If "Yes":
	Occupation					Name of Union or Local Number
12. Were you claiming or receiving unemployment prior to this disability?			Yes	No

If you did not claim or if you claimed but did not receive unemployment insurance benefits after LAST DAY WORKED, explain reasons fully:

If you did receive unemployment benefits, provide all periods collected:

13. For the period of disability covered by this claim:
A. Are you receiving wages, salary or separation pay?			Yes No
B. Are you receiving or claiming:		2. Paid Family Leave? Yes No
1. Unemployment Benefits?	Yes No

3.Workers' compensation for work-connected disability? Yes No

4.No-Fault motor vehicle accident? Yes No or personal injury involving third party? Yes No

5.Long-term disability benefits under the Federal Social Security Act for this disability? Yes No

IF "YES" IS CHECKED IN ANY OF THE ITEMS IN 13, COMPLETE THE FOLLOWING:

I have:

received

claimed from:

for the period:

to:

14. In the year (52 weeks) before your disability began, have you received disability benefits for other periods of disability?

If yes, Paid by:

from:

to:

Yes No

15. In the year (52 weeks) before your disability began, have you received Paid Family Leave?

If yes, Paid by:

from:

to:

Yes

16.If you became disabled while employed or within four weeks of your last day worked, did your employer provide you with your rights under Disability Law within 5 days of your notice or request for disability forms? Yes No

I hereby claim Disability Benefits and certify that for the period covered by this claim I was disabled. I have read the instructions on page 2 of this form and that the foregoing statements, including any accompanying statements are, to the best of my knowledge, true and complete.

Claimant's Signature

Date

An individual may sign on behalf of the claimant only if he or she is legally authorized to do so and the claimant is a minor, mentally incompetent or incapacitated. If signed by other than claimant, print information below and complete and submit Form OC-110A, Claimant's Authorization to Disclose Workers' Compensation Records.

On behalf of Claimant

Address

Relationship to Claimant

DB-450 (1-20) Page 1 of 2

PART 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 7-e. 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?:

Yes

From:

To:

6. Operation indicated?:

Yes

a. Type

b. Date

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

I certify that I am a:

(Physician, Chiropractor, Dentist, Podiatrist, Psychologist, Nurse-Midwife)

Licensed or Certified in the State of

License Number

Health Care Provider's Printed Name

Health Care Provider's Signature

Date

Health Care Provider's Address

Phone #

IMPORTANT NOTICE TO 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 and B 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 of your first date of disability 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, www.wcb.ny.gov, 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 MUST be mailed to: Workers' Compensation Board, Disability Benefits Bureau, PO Box 9029, Endicott, NY 13761-9029. If you answered "Yes" to question 13.B.3, please complete and attach Form DB-450.1.

If you do not receive a response within 45 days or if you have questions about your disability benefits claim, please call your employer's insurance carrier. For general information about disability benefits, please visit www.wcb.ny.gov or call the Board's Disability Benefits Bureau at (877) 632-4996.

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 part, you must file with the Board an original signed Form OC-110A "Claimants Authorization to Disclose Workers' Compensation Records." This form is available on the WCB website (www.wcb.ny.gov) and can be accessed by clicking the "Forms" link. If you do not have access to the internet please call (877) 632-4996 or visit our nearest Customer Service Center to obtain a copy of the form. In lieu of Form OC-110A, you may also submit an original signed, notarized authorization letter.

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.

DB-450 (1-20) Page 2 of 2

How to Edit Form Db 450 Disability Online for Free

We were designing this PDF editor with the prospect of allowing it to be as quick make use of as possible. This is the reason the process of completing the form db 450 is going to be effortless as you go through these actions:

Step 1: The first thing is to select the orange "Get Form Now" button.

Step 2: At this point, you are on the document editing page. You can add content, edit current data, highlight specific words or phrases, place crosses or checks, insert images, sign the file, erase unnecessary fields, etc.

Provide the necessary details in every segment to fill in the PDF form db 450

Enter the demanded particulars in My job is or was, Union Member, Yes, If Yes, Occupation, Name of Union or Local Number, Were you claiming or receiving, Yes, If you did not claim or if you, Mo Day Yr, Mo Day Yr, Mo Day Yr, Mo Day Yr, If you did receive unemployment, and For the period of disability box.

nys disability form My job is or was, Union Member, Yes, If Yes, Occupation, Name of Union or Local Number, Were you claiming or receiving, Yes, If you did not claim or if you, Mo Day Yr, Mo Day Yr, Mo Day Yr, Mo Day Yr, If you did receive unemployment, and For the period of disability blanks to complete

Inside the section referring to I hereby claim Disability Benefits, An individual may sign on behalf, Claimants Signature, Date, On behalf of Claimant, DB Page of, Address, and Relationship to Claimant, make sure you note some significant data.

nys disability form I hereby claim Disability Benefits, An individual may sign on behalf, Claimants Signature, Date, On behalf of Claimant, DB Page of, Address, and Relationship to Claimant blanks to insert

The PART B HEALTH CARE PROVIDERS, Last Name, First Name, Gender, Male, Female, Date of Birth, DiagnosisAnalysis, a Claimants symptoms, b Objective findings, Diagnosis Code, Claimant hospitalized, Operation indicated, Yes, and Yes box will be your place to put the rights and obligations of each party.

nys disability form PART B HEALTH CARE PROVIDERS, Last Name, First Name, Gender, Male, Female, Date of Birth, DiagnosisAnalysis, a Claimants symptoms, b Objective findings, Diagnosis Code, Claimant hospitalized, Operation indicated, Yes, and Yes fields to insert

Finalize by taking a look at all these areas and preparing them correspondingly: Health Care Providers Printed Name, Health Care Providers Signature, Date, Health Care Providers Address, Phone, IMPORTANT NOTICE TO CLAIMANT READ, PLEASE NOTE Do not date and file, If you are using this form, If you are using this form, If you do not receive a response, Notification Pursuant to the New, and HIPAA NOTICE In order to.

Step 3: Select the Done button to save the document. Now it is at your disposal for transfer to your gadget.

Step 4: To protect yourself from probable upcoming concerns, you should get as much as a pair of copies of each document.

Form Db 450 Disability – Fill Out and Use This PDF

Form Db 450 Disability PDF Details

Form Preview Example

How to Edit Form Db 450 Disability Online for Free

Watch Form Db 450 Disability Video Instruction

Form Db 450 Disability isn’t the one you’re looking for?

Please rate Form Db 450 Disability

Form Db 450 Disability – Fill Out and Use This PDF

Form Db 450 Disability PDF Details

Form Preview Example

How to Edit Form Db 450 Disability Online for Free

Watch Form Db 450 Disability Video Instruction

Form Db 450 Disability isn’t the one you’re looking for?

Related Documents

Please rate Form Db 450 Disability

Related Resources