7. ENTER DATES FOR THE FOLLOWING
PART B - HEALTH CARE PROVIDER'S STATEMENT (Please Print or Type)
3. Date of Birth:
/
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a. Claimant's symptoms:
b. Objective findings:
5. Claimant hospitalized?:
4. Diagnosis/Analysis: Diagnosis Code:
NoYes
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 9. INCOMPLETE ANSWERS MAY DELAY
PAYMENT OF BENEFITS.
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From:
To:
6. Operation indicated?:
NoYes
a. Type
b. Date
a Date of your first treatment for 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
c. Date Claimant was unable to work because of this disability
b. Date of your most recent treatment for this disability
DAY YEAR
No
Yes
8. In your opinion, is this disability the result of injury arising out of and in the course of employment or occupational disease?:
No
Yes
If "Yes", has Form C-4 been filed with the Board?
I certify that I am a:
License NumberLicensed or Certified in the State of
(Physician, Chiropractor, Dentist, Podiatrist, Psychologist, Nurse-Midwife)
Health Care Provider's Signature
Date
Health Care Provider's Printed Name
Phone #
Health Care Provider's Address
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 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 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 should be mailed to: Workers' Compensation Board, Disability Benefits Bureau, 328 State Street,
Schenectady, NY 12305. If you answered "Yes" to question 14.B.3, please complete and attach Form DB-450.1.
If you have any questions about claiming disability benefits, you may contact the Board's Disability Benefits Bureau at (800)
353-3092. Additional information may be obtained at the Board's website: www.wcb.ny.gov, or you may write to the Disability Benefits
Bureau at the address listed above.
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.
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 (9-17) Page 2 of 2
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/
/
/
1. Last Name: First Name: MI:
2.Gender:
Male Female
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
website, www.wcb.ny.gov. It can be found under Forms on the 'List of All Common Workers' Compensation Board Forms' web page. Mail the completed authorization form to
the address listed above.
MONTH
estimated delivery date OR
actual delivery date
