The DB 450 Disability form serves as a notice and proof of claim for disability benefits in New York State. This essential document requires detailed information from both the claimant and their healthcare provider to ensure a smooth processing of claims. To begin your application for disability benefits, fill out the form by clicking the button below.
The DB 450 Disability form is a crucial document for individuals seeking disability benefits in New York State. This form serves as a notice and proof of claim, ensuring that those who have become disabled can access the financial support they need during challenging times. It is divided into two main parts: Part A, which gathers essential information about the claimant, and Part B, which requires input from a health care provider. Claimants must provide personal details, including their name, contact information, social security number, and a description of their disability. Additionally, they need to indicate their employment history and any other benefits they might be receiving. The health care provider's section includes vital medical information, such as diagnosis, treatment dates, and the expected duration of the disability. Completing this form accurately and thoroughly is essential, as any omissions or inaccuracies could delay the processing of claims. Understanding the nuances of the DB 450 form can significantly impact a claimant's ability to receive timely benefits, making it essential for applicants to familiarize themselves with its requirements.
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 an essential step in claiming disability benefits. This form requires detailed information about your personal circumstances, your disability, and your employment history. Ensure that you have all necessary documents and information ready before starting the process.
Once the form is completed, it must be submitted to the appropriate party based on your employment status at the time of your disability. Ensure that you follow all instructions carefully to avoid any delays in processing your claim.
What is the DB 450 Disability form?
The DB 450 Disability form is a document used in New York State to apply for disability benefits. It serves as a notice and proof of claim for individuals who are unable to work due to a disability. The form collects essential information about the claimant, their disability, and employment history, which is necessary for processing the claim.
Who needs to fill out the DB 450 form?
The form must be completed by the claimant who is seeking disability benefits. Additionally, a health care provider must fill out Part B of the form to provide medical evidence supporting the disability claim. Both sections are crucial for the claim's approval.
How do I submit the DB 450 form?
If you became disabled while employed, you should mail the completed form to your employer or their insurance carrier within 30 days of your first date of disability. If you were unemployed for more than four weeks before becoming disabled, send the form to the Workers' Compensation Board, Disability Benefits Bureau, at the specified address in the instructions.
What information is required in Part A of the form?
Part A requires personal information about the claimant, including their name, address, Social Security number, date of birth, gender, and details about the disability. Claimants must also provide information about their last employer, employment history, and any other benefits they may be receiving.
What should I include in the description of my disability?
In the description section, clearly state the nature of your disability. If it resulted from an injury, include details about how, when, and where the injury occurred. Providing thorough information helps in assessing the claim more efficiently.
What if I have recovered from my disability?
If you have recovered from your disability, you need to indicate this on the form. Specify the date you were able to return to work. This information is vital for determining the duration of benefits you may receive.
Can I submit the DB 450 form before my disability begins?
No, you should not date and file the form prior to your first date of disability. Doing so may cause delays in processing your claim. Ensure that the form is completed accurately and submitted on time after your disability begins.
What happens if I do not receive a response after submitting the form?
If you do not receive a response within 45 days of submitting your claim, you should contact your employer's insurance carrier for updates. If you have questions about the claim process, you can also reach out to the Workers' Compensation Board's Disability Benefits Bureau.
What if I need to disclose my medical information?
The Workers' Compensation Board requires health care providers to file medical reports related to your treatment. This is necessary for adjudicating your claim. However, your personal information will be protected and disclosed only in accordance with applicable laws.
Are there penalties for providing false information on the DB 450 form?
Yes, knowingly providing false information on the form can lead to serious consequences, including criminal charges, fines, and imprisonment. It is crucial to ensure that all information provided is accurate and truthful to avoid legal repercussions.
Filling out the DB-450 Disability form can be a daunting task, and many individuals make mistakes that can lead to delays or even denials of their claims. Here are seven common errors to avoid when completing this important document.
First, many people overlook the importance of thoroughly reading the instructions on page 2 of the form. Skimming the instructions can lead to incomplete submissions. Each section is designed to gather specific information, and missing details can significantly slow down the processing of your claim.
Secondly, failing to answer all questions in Part A and the required questions in Part B is a frequent mistake. Each question is crucial for assessing your eligibility. If a question does not apply to you, it is still essential to indicate that, rather than leaving it blank. This clarity helps the reviewing party understand your situation better.
Another common error is not providing accurate dates, especially regarding when the disability began and when the claimant last worked. Inaccurate dates can create confusion and may lead to unnecessary delays in processing your claim. Always double-check these details before submitting your form.
Many claimants also forget to include their contact information accurately. Ensure that your mailing address, phone number, and email address are correct. This information is vital for any follow-up communication regarding your claim.
Additionally, some individuals neglect to disclose any other benefits they are receiving, such as unemployment or workers' compensation. Failing to provide this information can raise red flags and complicate your claim. Be transparent about all financial assistance you are receiving during your disability period.
Moreover, it is crucial to ensure that the health care provider's section is completed fully and accurately. If the health care provider fails to provide necessary details or signs the form, it can delay your claim significantly. Make sure to communicate with your provider to avoid this pitfall.
Lastly, many claimants forget to sign and date the form before submission. A missing signature can lead to outright rejection of your claim. Always double-check that you have signed the form and included the date of your signature.
By avoiding these common mistakes, you can streamline the process of applying for disability benefits. Take your time, review your answers, and ensure that all sections are completed accurately. Your attention to detail can make a significant difference in the outcome of your claim.
The DB-450 Disability form is a crucial document for individuals seeking disability benefits in New York State. However, there are several other forms and documents that often accompany this application to ensure a smooth and efficient claims process. Below is a brief overview of these related documents.
Each of these documents plays a vital role in the claims process, helping to establish eligibility and support the information provided on the DB-450 Disability form. By preparing these additional forms and documents in advance, claimants can help expedite their application and reduce the likelihood of delays in receiving benefits.
Things to Do When Filling Out the DB-450 Disability Form:
Things to Avoid When Filling Out the DB-450 Disability Form:
Misconceptions about the DB-450 Disability form can lead to confusion and delays in processing claims. Here are six common misconceptions:
Filling out the DB-450 Disability form is an important step in claiming your disability benefits. Here are some key takeaways to keep in mind:
By following these guidelines, you can help ensure a smoother process in obtaining your disability benefits. If you have questions, don't hesitate to reach out for assistance.