The DB-450 Disability form serves as a Notice and Proof of Claim for Disability Benefits in New York State, guiding claimants and healthcare providers through the process of documenting and claiming disability benefits. Essential for ensuring timely and appropriate benefits, the form stipulates comprehensive instructions for completion—requiring claimants to fill detailed personal, employment, and disability-specific information, and healthcare providers to furnish medical details substantiating the claim. To streamline your disability claim process, consider filling out the DB-450 form by clicking the button below.
The DB-450 form serves as a crucial document for residents of New York State seeking to claim disability benefits. This comprehensive form outlines the process for notifying the relevant authorities about a disability and provides a structured way for both claimants and health care providers to supply necessary information, ensuring a smooth benefits claim process. The form is divided into two main parts; Part A requires detailed input from the claimant regarding personal and employment information, specifics of the disability, and any other benefits being claimed. It emphasizes the need for thoroughness to avoid delays, especially regarding the description of the disability, the date it commenced, employment details before the disability, and any other compensation being received. Part B is dedicated to the health care provider's statement, which must be filled out completely and returned to the claimant within seven days of receipt. It requests specific medical details, including the diagnosis, treatment dates, and an estimation of when the claimant might return to work. The instructions stress strict timelines for submitting the form based on the claimant's employment status at the time of disability onset and highlight the implications of failing to provide accurate and timely information, both for receiving the benefits and for maintaining compliance with state law. Additionally, it briefly touches on the legal context and protections surrounding the form, including safeguards for the claimant's personal information in accordance with federal and state privacy laws.
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?:
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.
OTHER EMPLOYER (during last eight (8) weeks)
10. My job is or was:
11. Union Member:
No If "Yes":
Occupation
Name of Union or Local Number
12. Were you claiming or receiving unemployment prior to this disability?
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?
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:
15. In the year (52 weeks) before your disability began, have you received Paid Family Leave?
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
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:
2.Gender:
3. Date of Birth:
4. Diagnosis/Analysis:
Diagnosis Code:
a. Claimant's symptoms:
b. Objective findings:
5. Claimant hospitalized?:
From:
To:
6. Operation indicated?:
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?:
No If "Yes", has Form C-4 been filed with the Board?
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
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
Completing the DB-450 Disability form is a crucial step in applying for disability benefits. This form is your notice and proof of claim, which allows you to communicate your need for support due to a disability. Ensuring all the necessary details are included and accurately provided will help avoid delays in the processing of your claim. Below, you'll find straightforward instructions to complete the form correctly.
After completing these steps, review the form to ensure all information is accurate and complete. Missing or inaccurate details can delay the processing of your claim. If you are currently employed or were employed up to four weeks before your disability, submit your completed form to your employer or their insurance carrier. If you became disabled after more than four weeks of unemployment, mail your form to the address provided in the form instructions. Remember, this form is a key part of ensuring you receive the support you're entitled to, so take care in filling it out properly.
The DB-450 form is the official document used in New York State for filing a claim for disability benefits. It serves as both a notice and proof of a disability claim, requiring detailed information from the claimant and their health care provider to process the claim.
Individuals who become disabled while employed, or within four weeks of their last day of employment, need to complete the DB-450 form. Both Part A, which is filled out by the claimant, and Part B, which must be completed by the healthcare provider, are required for the claim to be processed.
It is recommended that the completed DB-450 form be mailed within thirty (30) days from the first day of disability. This helps in avoiding delays in the processing of the disability benefits claim.
The form requests detailed information including personal details, description of the disability, employment and wage details prior to the disability, and any other benefits being received or claimed. Health care providers must also provide specific details about the disability, including diagnosis, treatment dates, and prognosis.
If you are receiving or claiming other benefits like unemployment benefits, paid family leave, workers' compensation, no-fault motor vehicle accident benefits, or long-term disability benefits under the Federal Social Security Act for this disability, you must indicate this on the form. Details of such benefits or claims must be provided as requested in Section 13 of the form.
No, providing your social security number on the DB-450 form is voluntary. There is no penalty for not providing it, and it will not result in claim denial or reduction in benefits. However, the SSN helps in the expedient investigation and processing of claims.
After submission, if you do not receive a response within 45 days or if you have questions about your claim, you should contact your employer's insurance carrier. For general information, the Workers' Compensation Board's Disability Benefits Bureau is also available for contact.
The Workers' Compensation Board ensures the confidentiality of all personal information it holds, disclosing it only as necessary for official duties and in accordance with applicable laws. Should you choose to have your information disclosed to an unauthorized party, a formal authorization form or letter must be submitted.
Not answering all the required questions in Part A and the first three questions in Part B is a common pitfall. The form clearly instructs claimants to complete these sections thoroughly to prevent delays. Skipping any of these can halt the processing of your claim, leading to unnecessary delays in receiving your benefits.
Many individuals make the mistake of providing incomplete descriptions of their disability in question 7. It's crucial to provide a detailed account, especially if the disability is injury-related, including specifics like how, when, and where the injury occurred. This information is vital for the processing team to understand your situation fully and assess your claim accurately.
Omitting employer information, particularly when there has been more than one employer in the last eight weeks, is another common error found in question 9. Remember, your average weekly wage, which is critical in determining your benefit amount, is calculated based on your earnings from all employment in the preceding eight weeks. Failure to list all employers can lead to an incorrect benefit calculation.
Incorrectly reporting other income or benefits in question 13 can also lead to complications with your claim. Whether it's wages, unemployment benefits, paid family leave, workers' compensation, or any other form of income, it's essential to report these accurately. Misreporting can not only delay your claim but can also result in legal consequences for falsifying information.
A significant mistake is not ensuring that the healthcare provider completes Part B fully and returns it to you within seven days. The healthcare provider's statement is a crucial component of your disability claim, and incomplete answers in this section can delay the payment of benefits. Make sure to follow up with your healthcare provider to ensure this part is completed promptly.
In summary, to ensure a smooth process when filing your DB-450 form for disability benefits, pay special attention to accurately and thoroughly completing the form. Avoid the common mistakes listed above, and verify all sections, especially those requiring detailed descriptions and reports of other benefits or income. Remember, careful completion of your claim form can significantly expedite the processing and approval of your disability benefits.
Filing for disability benefits often requires more than just completing the DB-450 form. Understanding the range of forms and documents that might be needed can streamline the process and avoid delays. Here's a look at some of the other forms and documents that are frequently used together with the DB-450 form to ensure a comprehensive submission.
Each document plays a critical role in the disability benefits claim process, providing the necessary evidence and information to support the claim. Familiarity with these documents, along with a complete and accurate DB-450 form, can lead to a smoother and more efficient claim approval process. Seeking guidance from legal or human resources professionals is also advisable when navigating through these requirements.
The DB-100 form, titled "Notice and Proof of Claim for Disability Benefits," closely resembles the DB-450 as both serve the purpose of initiating a claim for disability benefits. The DB-100 form also requires claimants to provide their personal information, details regarding their disability, and their employment history to process a disability claim efficiently.
The DB-300 form, known as "Claim for Disability Benefits," shares similarities with the DB-450, as it too requires claimants to furnish detailed personal and employment information. Additionally, it asks for specific information about the nature of the disability and the expected duration of the inability to work, akin to the DB-450's content structure.
Form SS-5, the application for a Social Security Card, although primarily for a different purpose, gathers detailed personal information similar to the DB-450. Both forms collect data like name, mailing address, social security number, and birth date, which are fundamental for identification and processing.
The W-4 form, "Employee's Withholding Certificate," while primarily used for tax withholding purposes, requires detailed personal information and, sometimes, information about employment similar to the DB-450. This includes identification information that assists in the management of financial matters related to employment.
Workers' Compensation Claim Form (WC-100), parallels the DB-450 in that it is designed for workers who have been injured or have fallen ill due to their job. Both forms necessitate detailed information about the claimant, their employment, and specifics about the injury or illness, establishing their eligibility for benefits.
The Family Medical Leave Act (FMLA) application form bears resemblance to the DB-450 by requiring personal information, details on the medical condition, and information regarding employment. Although FMLA is for unpaid leave, both documents similarly aim to provide relief to employees based on their health-related circumstances.
Short-Term Disability Claim Form, like the DB-450, is used by individuals seeking benefits due to a temporary inability to work because of a disability. It collects comprehensive information about the claimant's job, the medical condition affecting their ability to work, and the anticipated return date to work.
Long-Term Disability Claim Form is akin to the DB-450 as it collects extensive details about the claimant, including their employment, the nature of their disability, and the long-term impacts on their working capabilities. Though it focuses on longer periods of disability, the necessity for detailed personal, employment, and medical information parallels that of the DB-450.
Filling out the DB-450 Disability Form is crucial for ensuring that disability benefits claims are processed efficiently and correctly. Here are some important dos and don'ts to follow:
By paying close attention to these dos and don'ts, claimants can enhance the accuracy of their submitted information and help expedite the processing of their disability benefits claim.
Misconceptions about the DB-450 Disability Form can lead to confusion and delays in processing claims for disability benefits. Let's clarify some of the common misunderstandings surrounding this form.
Dispelling these misconceptions ensures a smoother process for claimants seeking disability benefits. It is always advisable to read instructions carefully and comply with the required timelines and submission protocols as outlined by the Workers' Compensation Board.
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