NYS Form NF-3 PDF Details

Working with forms can be a daunting task, particularly when it comes to creating and filling out forms online. Fortunately, technology has made this process much simpler. By leveraging document automation software, you can easily create and accurately fill out digital forms. In this blog post, we'll look at what precisely the NYS Form NF-3 is designed to do and how it works in practice so that you can get the most from your form-filling activities.

QuestionAnswer
Form Name Form Nf 3
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names no fault forms nf3, new york state no fault forms, form nf 3 no fault, fillable nys form nf 3

Form Preview Example

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)

NAME AND ADDRESS OF INSURER OR SELF-INSURER

Government Employees Insurance Company

NY PIP

PO Box 9507

Fredericksburg, VA 22403-9526

NAME, ADDRESS & PHONE NUMBER OF INSURER’S

CLAIMS REPRESENTATIVE

GEICO

NY PIP

PO Box 9507

Fredericksburg, VA 22403-9526

FAX: 856-294-5154

DATE

POLICYHOLDER

POLICY NUMBER

DATE OF ACCIDENT

CLAIM NUMBER

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

2. AGE

3. SEX

4. OCCUPATION (IF KNOWN)

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?

YES NO IF "YES", DESCRIBE:

NOT DETERMINABLE AT THIS TIME

12.PATIENT WAS DISABLED (UNABLE TO WORK)

FROM:THROUGH:

13. IF STILL DISABLED THE PATIENT SHOULD BE ABLE

TO RETURN TO WORK ON:

(DATE)

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.

C345(11-09)

NYS FORM NF-3

(PAGE 2)

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

15. REPORT OF SERVICES RENDERED

DATE OF SERVICE

PLACE OF SERVICE

INCLUDING ZIP CODE

DESCRIPTION OF TREATMENT OR

HEALTH SERVICE RENDERED

FEE SCHEDULE

TREATMENT CODE

CHARGES

 

 

 

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.”

DATE

PROVIDER’S SIGNATURE

IRS/TIN IDENTIFICATION NO.

WCB RATING CODE IF NONE, SPECIALTY

C345(11-09)

NYS FORM NF-3

How to Edit NYS Form NF-3 Online for Free

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With regards to the fields of this particular document, this is what you should know:

1. Complete your nf form 3 with a selection of essential fields. Gather all the necessary information and be sure not a single thing overlooked!

The right way to fill out nys no fault forms portion 1

2. Once your current task is complete, take the next step – fill out all of these fields - IS CONDITION SOLELY A RESULT OF, NO IF NO explain, YES, IS CONDITION DUE TO INJURY, YES, WILL INJURY RESULT IN SIGNIFICANT, YES, NOT DETERMINABLE AT THIS TIME, IF YES DESCRIBE, PATIENT WAS DISABLED UNABLE TO, No IF YES DESCRIBE YOUR, YES, IF STILL DISABLED THE PATIENT, C NYS FORM NF, and NOTE COMPLETE REVERSE SIDE AND SIGN with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

nys no fault forms conclusion process clarified (portion 2)

3. The next segment is pretty uncomplicated, DATE OF SERVICE, PLACE OF SERVICE, INCLUDING ZIP CODE, DESCRIPTION OF TREATMENT OR, HEALTH SERVICE RENDERED, FEE SCHEDULE, TREATMENT CODE, CHARGES, TOTAL CHARGES TO DATE, IF TREATING PROVIDER IS DIFFERENT, TREATING PROVIDERS, NAME, TITLE, LICENSE OR, and CERTIFICATION NUMBER - every one of these empty fields needs to be filled out here.

Part # 3 in filling in nys no fault forms

Regarding LICENSE OR and DATE OF SERVICE, ensure that you don't make any errors in this section. The two of these could be the most significant ones in the form.

4. This next section requires some additional information. Ensure you complete all the necessary fields - OPTIONAL ASSIGNMENT OF NOFAULT, IRSTIN IDENTIFICATION NO, PROVIDERS SIGNATURE, WCB RATING CODE, C NYS FORM NF, and IF NONE SPECIALTY - to proceed further in your process!

nys no fault forms completion process clarified (portion 4)

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