Form Db 450 Disability PDF Details

Form Db 450 disability is a form that you will need to fill out in order to apply for disability benefits. This form can be complex, so it is important that you understand what is required before submitting your application. In this blog post, we will provide an overview of Form Db 450 and explain the steps involved in completing the application. We will also discuss the eligibility requirements for disability benefits and offer tips for preparing your application.

This information will allow you to understand better the details of the form db 450 disability before you start filling it out.

QuestionAnswer
Form NameForm Db 450 Disability
Form Length2 pages
Fillable?Yes
Fillable fields1
Avg. time to fill out42 sec
Other namesshort term disability ny form, new york state short term disability form, db450 form, nys short term disability form

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)

1.

Last Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

MI:

 

 

2.

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

No

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

 

(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

 

(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

/

No

/

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

No

From:

 

 

 

/

 

 

/

 

 

To:

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(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 new york state short term disability form 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 new york state short term disability form

nys short term disability form gaps to fill in

Enter the demanded particulars in FirmorTradeName, Address, PhoneNumber, FirstDay, LastDayWorked, OTHEREMPLOYERduringlasteightweeks, MoDayYr, MoDayYr, PERIODOFEMPLOYMENT, FirmorTradeName, Address, PhoneNumber, FirstDay, LastDayWorked, and AverageWeeklyWageIncludeBonusesTips box.

nys short term disability form FirmorTradeName, Address, PhoneNumber, FirstDay, LastDayWorked, OTHEREMPLOYERduringlasteightweeks, MoDayYr, MoDayYr, PERIODOFEMPLOYMENT, FirmorTradeName, Address, PhoneNumber, FirstDay, LastDayWorked, and AverageWeeklyWageIncludeBonusesTips blanks to complete

Inside the section referring to IfyesPaidby, from, Yes, Yes, ClaimantsSignature, Date, OnbehalfofClaimant, DBPageof, Address, and RelationshiptoClaimant, make sure you note some significant data.

nys short term disability form IfyesPaidby, from, Yes, Yes, ClaimantsSignature, Date, OnbehalfofClaimant, DBPageof, Address, and RelationshiptoClaimant blanks to insert

The DiagnosisCode, DateofBirth, Male, Female, FirstName, aClaimantssymptoms, bObjectivefindings, Claimanthospitalized, aType, YesYes, NoNo, From, bDate, DAY, and MONTH box will be your place to put the rights and obligations of each party.

nys short term disability form DiagnosisCode, DateofBirth, Male, Female, FirstName, aClaimantssymptoms, bObjectivefindings, Claimanthospitalized, aType, YesYes, NoNo, From, bDate, DAY, and MONTH fields to insert

Finalize by taking a look at all these areas and preparing them correspondingly: LicensedorCertifiedintheStateof, LicenseNumber, HealthCareProvidersPrintedName, HealthCareProvidersSignature, Date, HealthCareProvidersAddress, and Phone.

Filling in nys short term disability form step 5

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.

Watch Form Db 450 Disability Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .