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19 views1 page

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Uploaded by

Amy lee Lee
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TERM INATION OF EMPLOYMENT . OTHERW ISE USE CLAIM FORM DB-300.
PART B - HEALTH CARE PROVIDER'S STATEMENT (Pl ease Print or Type)
THE HEALTH CARE PROVIDER'S STATEMENT MUST BE FILLED IN COMPLETELY AND THE FORM MAILED TO THE
INSURANCE CARRIER OR SELF-INSURED EMPLOYER , OR RETURNED TO THE CLAIMANT WITHIN SEVEN DAYS OF THE

81, In
RECEIPT OF THE FORM . For item 7d, give approxi mate date. Make some estimate. If disability is caused by or arising in
connection with pregnancy, ente r estimated delivery date under " Remarks" .
1. Claimant's Name ... T..a,._
J(!)..fL.(1_--:'!:-.. .. ~ .{p _c_ _............. 2. Date of Birth ..... .. .. .... 3. Sex □ Male X"'Female
/JJ.~ ~-ti.,f.t;}..,.I',' ······--···· . ·········· ... ... iagnosi
~-~ -~z ~~~·m.
4. Diagn?sis/Analys1s ..

-.' ikc.~)l!ltft!~./-~-- •-A. ,Oc. . . .~


b:·o"bj·;~ti~~-Fi·· ··i~--;··.·.·. u~2~.~ - -·_~ .--·:··;.ltiJi~Jx/ iit~At.?i;:.·.~
Co e ....... .. ........ .

--.·.~
....... ~ .-~ ... .... .. IU>V~./.~ .... .. ..... .. ...... ............ ... .... ........ ... .. .. .. ....... ........ ...... .

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5. Claimant Hospitalized? □ Yes From ... .. .. ......... .... ... .. ... ... ...... ........ To .. ...... .. ... .. ... ... ..... ... ....... .. ...... . ..
6 . Operation Indicated? □ Yes a . Type . . . .. .. . . .. . .. .. . .. . .. .. . . .. . .. . .. . .. .. .. .. b. Date ... .. .. .... .. .. ...... ........ ........ .
7. Enter Dates for the Following:
a. Date of your first treatment fo r this disability ...... ... ................ ..... ............. 1--~1 - . - - ---1----1c-- - , , .= :.,...=:...=c-~
b. Date of your most recent treatment fo r this disability ....................... .... .. ..
c. Date claimant was unable to work because of this disability .................. ..
d. Date cla imant will be able to perform usual work ..................... ..... .. ...... ..
(Even ii considerable question exists , estimate daie. Avoid use of terms such as nknown or undetermined.)
8. In your opinion, is thift <;l isability the result of injury aris ing out of and in the course of employ
disease? □ Yes \lit_ No
If yes, has form C-4 been filed with the Workers' Compensation Board ? □ Yes □ No
Remarks (attach additional sheet, if necessary) .................................. .. ..... .. .. ........ .... .... .. ...... .. .. .. ......... .. ............. ..
(II disability is pregna ncy rel aie d. please enter estim ate d delivery

I affirm that 0 Chiropractor □ Psychologist License Number


I ama □ Dentist □ Nurse-Midwife al?..,?. 7
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PR ESENTED. OR PREPARE S WITH KNOWLEDGE OR BE LI EF
THAT IT 11\RL BE PRESE , TED O OR BY AN INSURER , OR SELF- SURER , ANY INFORMATION CONTAININ G ANY FALS E MATERIAL STATEMENT OR
CONCEALS ANY MATERIAL FACT SHA LL BE GUil TY OF A CRIME A JECT TO SUBSTANTIAL FINES AND IMPRISON\.IENT.

HIPAA NOTICE - In order lo adj udicate a worke rs.' compensation cla im , WCL 13-a( ) and 12 YCRR 325-1.3 require ea Ith care providers to regu larly file medi cal
re port s of tre atment with ihe Boa rd and the carrie r or employer. P rsua nt io 4 CFR 164.512 the se legally required medical reports are exempt fro m HIPM 's
restrictions on discl os ure of health information.

fo_y'. ~ s <Z5 - 3 3 &- / c7 73 1

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0 B-450 Reverse (2-04) THE WORKERS' CO \I\PENSATION BOARD EMPLOYS ANO SERVES PEOP LE WITH DISABILITIES WIT HOUT DI SCR IMINATION.

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