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The DB 450 Disability form is an essential document for individuals seeking disability benefits in New York State. Designed to streamline the claims process, this form requires claimants to provide detailed personal information, including their name, address, and Social Security number. Claimants must describe the nature of their disability, including when it occurred and whether they have recovered. Additionally, the form asks about employment history and any wages received during the disability period. Part A focuses on the claimant's information, while Part B is dedicated to the health care provider’s assessment, which must be filled out completely to avoid delays. Health care providers need to offer insights into the diagnosis, treatment dates, and the claimant's ability to work. Completing the DB 450 accurately and promptly is crucial, as it directly impacts the processing of claims for disability benefits. The instructions on the form guide users on how to submit it correctly, ensuring that all necessary information is included to facilitate a smooth claims experience.

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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?:

Yes

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.

Mo.

Day

Yr.

 

OTHER EMPLOYER (during last eight (8) weeks)

 

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.

Mo.

Day

Yr.

 

 

 

 

 

Mo.

Day

Yr.

Mo.

Day

Yr.

 

10. My job is or was:

 

11. Union Member:

Yes

No If "Yes":

 

Occupation

 

 

 

 

Name of Union or Local Number

12. Were you claiming or receiving unemployment prior to this disability?

Yes

No

 

 

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?

Yes No

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:

 

/

 

/

 

to:

 

/

 

/

/

Yes No

15. In the year (52 weeks) before your disability began, have you received Paid Family Leave?

If yes, Paid by:

from:

/

/

to:

Yes

/

No

/

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

Address

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI:

 

 

2.Gender:

Male

Female

 

3. Date of Birth:

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Diagnosis/Analysis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis Code:

 

 

 

 

 

 

 

 

 

 

a. Claimant's symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Objective findings:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Claimant hospitalized?:

Yes

No

From:

 

 

 

/

 

 

/

 

 

To:

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Operation indicated?:

Yes

No

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?:

 

Yes

No If "Yes", has Form C-4 been filed with the Board?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

➤ PDF File

Form Specifications

Fact Name Fact Description
Form Purpose The DB-450 form is used to file a claim for disability benefits in New York State.
Claimant Information Part A requires the claimant's personal details, including name, address, and social security number.
Health Care Provider Part B must be completed by a health care provider who treats the claimant for their disability.
Submission Timeline Claims should be submitted within 30 days of the first date of disability to avoid delays.
Governing Law The DB-450 form is governed by New York Workers' Compensation Law.
Eligibility Requirements Claimants must provide proof of their disability and may need to show employment history.
Signature Requirement The claimant must sign the form, certifying that the information is true and complete.
Incomplete Submissions Failure to complete all required sections may delay the processing of the claim.
Privacy Notice The form includes a privacy notice regarding the handling of personal information.
Contact Information For questions, claimants can contact the Workers' Compensation Board at (877) 632-4996.

Db 450 Disability: Usage Guidelines

Completing the DB-450 Disability form is an essential step in filing a claim for disability benefits. This process requires attention to detail and accurate information to ensure timely processing. Below are the steps to guide you through filling out the form effectively.

  1. Part A - Claimant's Information:
    • Write your last name, first name, and middle initial in the designated fields.
    • Provide your mailing address, including street, apartment number, city, state, and zip code.
    • Enter your daytime phone number and email address.
    • Fill in your Social Security number.
    • Indicate your date of birth.
    • Select your gender (Male or Female).
    • Describe your disability, including how, when, and where it occurred if it was an injury.
    • State the date you became disabled.
    • Indicate whether you worked on the day you became disabled (Yes or No).
    • Answer if you have recovered from the disability and provide the return-to-work date if applicable.
    • List the name of your last employer prior to the disability, including the period of employment and average weekly wage.
    • If you had other employers in the last eight weeks, provide their details as well.
    • Describe your job title or occupation.
    • Indicate if you are a union member and provide the union name and local number if applicable.
    • Answer whether you were claiming or receiving unemployment prior to the disability.
    • For the period of disability, answer questions regarding any wages, paid family leave, unemployment benefits, workers' compensation, and long-term disability benefits.
    • Disclose if you received disability benefits for other periods in the year before your current disability.
    • Confirm if your employer provided you with your rights under Disability Law if you became disabled while employed or shortly after.
  2. Part B - Health Care Provider's Statement:
    • Have your health care provider fill out their information, including name, gender, and date of birth.
    • Provide a diagnosis or analysis, including the diagnosis code.
    • Indicate whether the claimant was hospitalized and the dates of hospitalization.
    • State if any operations are indicated and provide details.
    • Enter the dates of treatment, including the first treatment date and the most recent treatment date.
    • Provide the date the claimant was unable to work due to the disability and the estimated date they will be able to return to work.
    • Confirm if the disability is work-related and if Form C-4 has been filed with the Board.
  3. Final Steps:
    • Review all information for accuracy and completeness.
    • Sign the form and date it. If someone else is signing on your behalf, ensure they are legally authorized to do so.
    • Submit the completed form to the appropriate party based on your employment status at the time of disability.

Once the form is submitted, the next steps involve waiting for processing. You may receive a response within 45 days, or you can reach out to your employer's insurance carrier for updates. Understanding this process can help alleviate some of the stress associated with filing for disability benefits.

Your Questions, Answered

What is the DB 450 Disability form?

The DB 450 Disability form is a claim form used in New York State to apply for disability benefits. It serves as a notice and proof of claim for individuals who have become disabled and are seeking financial assistance during their recovery period.

Who needs to fill out the DB 450 form?

Both the claimant and their healthcare provider must complete the form. The claimant provides personal information and details about their disability, while the healthcare provider fills out their section to verify the disability and provide medical information.

What information is required from the claimant?

The claimant must provide personal details such as their name, address, phone number, Social Security number, date of birth, and gender. Additionally, they must describe their disability, including when and how it occurred, and provide information about their employment history and any other benefits they may be receiving.

How should the form be submitted?

The completed form should be mailed to the claimant's employer or the employer's insurance carrier if the disability occurred while employed or within four weeks after leaving a job. If the claimant has been unemployed for over four weeks, the form should be sent to the Workers' Compensation Board's Disability Benefits Bureau.

What happens if the form is incomplete?

If the form is incomplete, it may delay the processing of the claim. It is essential to answer all questions fully and accurately to avoid any issues with benefit payments.

How long does it take to process the claim?

The processing time can vary, but claimants should expect a response within 45 days. If there are any questions or concerns, it is advisable to contact the employer's insurance carrier for updates on the claim status.

Can the claimant authorize someone else to sign the form?

Yes, an individual may sign on behalf of the claimant if they are legally authorized to do so. This is typically applicable for minors or individuals who are mentally incompetent or incapacitated.

What if the claimant has received disability benefits in the past?

The claimant must disclose any previous disability benefits received in the year before the current claim. This information is crucial for determining eligibility and the amount of benefits that may be awarded.

Is it necessary for the healthcare provider to fill out their section promptly?

Yes, the healthcare provider must complete their section and return it to the claimant within seven days of receiving the form. Timely submission helps ensure that the claim is processed without unnecessary delays.

What should the claimant do if they have questions about the form?

If the claimant has questions about the DB 450 form or the disability benefits process, they can visit the Workers' Compensation Board's website or call the Disability Benefits Bureau for assistance.

Common mistakes

  1. Incomplete Information: Many individuals fail to provide all necessary details in Part A. Missing information, such as the Social Security number or mailing address, can lead to delays in processing the claim.

  2. Not Following Instructions: Ignoring the instructions on page 2 can create problems. Each section must be completed as directed to ensure a smooth processing experience.

  3. Incorrect Dates: People often make mistakes when entering dates, particularly the date of disability onset. Providing accurate dates is crucial for determining eligibility.

  4. Missing Employer Information: If you had multiple employers in the eight weeks before your disability, it’s important to list all of them. Omitting any employer can result in an inaccurate assessment of your claim.

  5. Failure to Sign: Some claimants forget to sign the form. A missing signature invalidates the claim, causing further delays.

  6. Neglecting to Include Health Care Provider’s Statement: The health care provider must complete Part B. If this section is not filled out completely, it can hinder the approval of benefits.

Documents used along the form

The DB 450 Disability form is essential for filing a claim for disability benefits in New York State. However, there are additional forms and documents that may be required to support your claim. Below is a list of these documents, along with brief descriptions of each.

  • Form DB-450.1: This form is used to provide additional information if you are receiving workers' compensation for a work-related disability. It helps ensure that all relevant details are included in your claim.
  • Form OC-110A: This is the Claimant's Authorization to Disclose Workers' Compensation Records. It allows you to authorize the release of your medical records to the appropriate parties, ensuring that your claim can be processed without delays.
  • Health Care Provider's Statement: Often included with the DB 450 form, this statement must be completed by your healthcare provider. It provides necessary medical information regarding your disability, including diagnosis and treatment dates.
  • Proof of Income Documentation: This may include pay stubs, tax returns, or other financial records to verify your income prior to the disability. This documentation helps determine your average weekly wage for benefits calculation.
  • Unemployment Benefits Documentation: If you were receiving unemployment benefits before your disability, you may need to provide documentation related to those benefits. This helps clarify your financial situation during the claim process.

Having these documents ready can streamline the claims process and reduce the likelihood of delays. Ensure that all information is accurate and complete to support your claim effectively.

Similar forms

  • Form DB-450.1: This form is used to provide additional information when claiming disability benefits. Like the DB-450, it requires details about the claimant's disability and any other benefits received, ensuring a comprehensive claim process.
  • Workers' Compensation Claim Form (C-3): This document is for individuals seeking compensation for work-related injuries. Both forms require detailed information about the claimant's condition and employment history, helping to establish eligibility for benefits.
  • Unemployment Insurance Claim Form: Individuals applying for unemployment benefits must complete this form. Similar to the DB-450, it gathers information about the claimant's work history and reasons for unemployment, which helps determine eligibility.
  • Paid Family Leave Application: This form is for those seeking paid family leave benefits. It shares similarities with the DB-450 in that both require information about the claimant's situation and any other benefits being claimed.
  • Social Security Disability Insurance (SSDI) Application: This application is for individuals applying for federal disability benefits. Like the DB-450, it necessitates detailed medical and employment history to assess the claimant's eligibility for assistance.
  • Long-Term Disability Claim Form: This form is used for claims related to long-term disability insurance. Both the long-term disability form and the DB-450 require medical verification and employment details to process claims effectively.
  • Family and Medical Leave Act (FMLA) Certification: This document certifies a need for leave due to medical reasons. Similar to the DB-450, it requires health care provider information and details about the claimant's condition.
  • Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: This form allows for the sharing of medical information. Both forms emphasize the importance of privacy and require consent for the release of sensitive information.
  • Employer's Report of Injury (C-2): This report is completed by employers when an employee is injured on the job. It parallels the DB-450 in that it documents the circumstances surrounding a disability and is crucial for claims processing.
  • Claimant's Authorization to Disclose Workers' Compensation Records (OC-110A): This form allows claimants to authorize the release of their records. Like the DB-450, it is essential for ensuring that all relevant information is available for the claims process.

Dos and Don'ts

When filling out the DB-450 Disability form, it’s essential to be thorough and accurate. Here’s a helpful list of things to do and avoid to ensure your claim is processed smoothly.

  • Do read the instructions carefully on page 2 before starting.
  • Do answer all questions in Part A and questions 1 through 3 in Part B.
  • Do provide complete and truthful information about your disability.
  • Do ensure your health care provider fills out Part B accurately.
  • Do mail the completed form within 30 days of your first date of disability if you were employed.
  • Do keep a copy of the completed form for your records.
  • Do follow up with your employer’s insurance carrier if you don’t receive a response within 45 days.
  • Don't leave any questions unanswered; incomplete forms may delay processing.
  • Don't submit the form before your first date of disability.
  • Don't provide false information, as this can lead to serious consequences.
  • Don't forget to check the box if your disability is pregnancy-related.
  • Don't hesitate to ask for assistance if you have questions about the form.
  • Don't assume your claim will be automatically approved; follow up as needed.
  • Don't overlook the importance of submitting all required documentation along with your claim.

By keeping these points in mind, you can navigate the process more effectively and increase the likelihood of a successful claim.

Misconceptions

Understanding the DB-450 Disability form is crucial for anyone seeking disability benefits in New York State. However, several misconceptions can lead to confusion and delays in processing claims. Below are four common misconceptions explained.

  • Misconception 1: The form can be submitted without completing all sections.

    • Many individuals believe they can skip certain sections of the DB-450 form. In reality, all questions in Part A and specific questions in Part B must be answered completely. Incomplete forms can result in delays in processing your claim.

  • Misconception 2: Only medical professionals need to fill out Part B.

    • Some claimants think that Part B of the form, which is the Health Care Provider's Statement, is solely the responsibility of their healthcare provider. While it is true that a healthcare provider must complete this section, claimants also have a role in ensuring that their provider submits the form within the required timeframe.

  • Misconception 3: Submitting the form late will not affect my claim.

    • There is a belief that submitting the DB-450 form late will not impact the claim. However, if the form is not mailed within 30 days of the first date of disability, it may lead to a denial of benefits. Timeliness is essential in the claims process.

  • Misconception 4: My Social Security number is mandatory for processing my claim.

    • Many people assume that providing their Social Security number is mandatory. While it is requested for identification purposes, it is voluntary. Not providing it will not lead to a denial of your claim or a reduction in benefits.

Key takeaways

  • Complete All Sections: Ensure that you fill out every question in Part A and the first three questions in Part B. Incomplete forms can lead to delays.
  • Provide Accurate Information: Double-check your personal details, including your name, address, and Social Security number, to avoid any discrepancies.
  • Disability Description: Clearly describe your disability, including how, when, and where it occurred. This information is crucial for your claim.
  • Employer Information: List all employers you worked for in the eight weeks prior to your disability, along with your average weekly wage. This helps establish your eligibility for benefits.
  • Healthcare Provider's Role: Your healthcare provider must complete Part B. They need to provide a detailed statement about your condition and treatment.
  • Timely Submission: Submit your completed form within 30 days of your first date of disability if you were employed, or send it to the Workers' Compensation Board if you were unemployed for over four weeks.
  • Follow-Up: If you do not receive a response within 45 days, contact your employer's insurance carrier for updates on your claim status.
  • Understand Your Rights: If you became disabled while employed, ensure your employer provided you with information about your rights under Disability Law within five days of your notice.
  • Privacy Protection: Your personal information is protected under state and federal laws. Providing your Social Security number is voluntary and will not affect your claim.