NYS Form NF-3 – Fill Out and Use This PDF

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW

VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE

(This form is not for verification of hospital treatment)

PROVIDER’S NAME AND ADDRESS

KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST

BE SUBMITTED TO INSURER NO LATER THAN 180 DAYS AFTER TREATMENT DATE.

IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY CHANGES FROM THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES.

1. PATIENT’S NAME AND ADDRESS

5.	DIAGNOSIS AND CONCURRENT CONDITIONS
6.	WHEN DID SYMPTOMS FIRST APPEAR?			7. WHEN DID PATIENT FIRST CONSULT YOU FOR THIS
	DATE:			CONDITION? DATE:
8.	HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
	YES	NO	IF "YES", state when and describe:
9.	IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT?
	YES	NO	IF "NO", explain:

10.IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT’S EMPLOYMENT?

YES NO

11.WILL INJURY RESULT IN SIGNIFICANT DISFIGUREMENT OR PERMANENT DISABILITY?

14. WILL THE PATIENT REQUIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE INJURIES SUSTAINED IN THIS ACCIDENT?

YES	No IF "YES", DESCRIBE YOUR RECOMMENDATION BELOW:

NOTE: COMPLETE REVERSE SIDE AND SIGN.

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VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE

15. REPORT OF SERVICES RENDERED

			TOTAL CHARGES TO DATE $
16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOWING:
TREATING PROVIDER’S	TITLE	LICENSE OR		BUSINESS RELATIONSHIP
NAME		CERTIFICATION NUMBER		CHECK APPLICABLE BOX
			EMPLOYEE		INDEPENDENT	OTHER (SPECIFY)
					CONTRACTOR

17.IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Provide an additional attachment if necessary).

18. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION?	YES	NO
19. ESTIMATED DURATION OF FUTURE TREATMENT

(OPTIONAL) 20.

I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE NO- FAULT PROVISION) OF THE INSURANCE LAW.

SIGNED ____________________________________________________________

(PATIENT)

OR

(OPTIONAL) 21. ASSIGNMENT OF NO-FAULT BENEFITS:

I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE NO-FAULT PROVISION) OF THE INSURANCE LAW. THIS AGREEMENT SHALL BECOME NULL AND VOID IF AT ANY TIME IT IS DETERMINED THAT BENEFITS ARE NOT PAYABLE DUE TO THE FOLLOWING CIRCUMSTANCES: LACK OF COVERAGE, VIOLATION OF A POLICY CONDITION, OR DETERMINATION THAT THE TREATMENTS/SERVICES RENDERED ARE NOT RELATED TO SAID MOTOR VEHICLE ACCIDENT. ANY PAYMENT PURSUANT TO THIS ASSIGNMENT SHALL NOT EXCEED THE HEALTH CARE PROVIDER’S PERMISSABLE CHARGES UNDER SAID ARTICLE 51. THE PROVIDER OF HEALTH SERVICES CERTIFIES THAT THEY HAVE NOT RECEIVED ANY PAYMENT FROM OR ON BEHALF OF THE INJURED PARTY AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE INJURED PARTY FOR SERVICES PROVIDED DUE TO INJURIES SUSTAINED IN RELATION TO THE AUTOMOBILE ACCIDENT.

SIGNED ____________________________________________________________

(PATIENT)

SIGNED ____________________________________________________________

(PROVIDER OF HEALTH CARE SERVICE)

“ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.”

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