New York auto insurers use this prescribed no-fault claim form to verify treatment by a physician or other non-hospital provider after a motor vehicle accident. It reports diagnosis, causation, disability dates, rehabilitation needs and services with fee schedule codes and charges, and can carry the patient's authorization to pay or assignment of benefits. The insurer treats it as proof of claim before paying basic economic loss benefits.
The attending physician or other provider of health service, such as a chiropractor, physical therapist, acupuncturist or psychologist, completes items 1 to 19 and signs page 3. The insurer may pre-fill its own name, claims representative and claim fields, and the patient signs item 20 or item 21 if direct payment or an assignment is chosen, with the provider countersigning an assignment.
The top of page 1 holds the insurer or self-insurer's name and address, the claims representative, the date, policyholder, policy number, date of accident, claim number, and the provider's name and address. Starred fields are language filled in by the insurer, so insurer-issued copies may arrive with them completed. Check that the claim number and accident date match the patient's claim. If an earlier NF-3 was already sent for this accident, the form says you need only note changes and additional charges.
Enter the patient's name and address (item 1), date of birth (item 2), sex (item 3) and occupation if known (item 4). These identify the patient on the claim, so keep them consistent with the CMS-1500 or other bill sent with the form and with the claim details at the top of the page.
Item 5 asks for the diagnosis and concurrent conditions. Items 6 and 7 record when symptoms first appeared and when the patient first consulted you. Item 8 asks whether the patient ever had the same or a similar condition, with when and a description if yes. Item 9 asks whether the condition is solely a result of this automobile accident, with an explanation if not, and item 10 whether it arose out of the patient's employment. Item 11 asks whether the injury will result in significant disfigurement or permanent disability: yes (describe), no, or not determinable at this time.
Item 12 records the dates the patient was disabled, meaning unable to work, from and through. Item 13 gives the date the patient should be able to return to work if still disabled. Item 14 asks whether the patient will require rehabilitation and/or occupational therapy as a result of the injuries sustained in this accident; if yes, describe your recommendation in the space provided.
List each date of service, the place of service including ZIP code, a description of the treatment or health service rendered, the fee schedule treatment code and the charge, then total charges to date. Attach additional sheets if needed. Charges follow the no-fault fee schedules adopted under Regulation 83, and DFS guidance says services without a listed unit value are billed 'by report' with a written report.
If the treating provider is different from the billing provider, item 16 asks for the treating provider's name, title, license or certification number and business relationship: employee, independent contractor or other. Item 17 asks a professional service corporation, or a practice doing business under an assumed name (DBA), to list all owners and their professional licensing credentials. Item 18 asks whether the patient is still under your care for this condition, and item 19 the estimated duration of future treatment.
Item 20 lets the patient authorize the insurer to pay the provider directly while keeping all rights under Article 51 of the Insurance Law. Item 21 is a full assignment signed by the patient (assignor) and the provider (assignee), in which the provider certifies it has received no payment from or on behalf of the patient and will not pursue the patient. Choosing one rules out the other. The assignment wording is mandatory and may not be altered by any other agreement.
Answer whether an original authorization or assignment was previously executed and whether the original signatures of the parties are on file. Below the fraud warning, the provider signs and dates the form and enters the IRS/TIN identification number and the WCB rating code or, if none, the specialty. Regulation 68 lets the insurer request the original authorization or assignment in writing, so keep it available.
Download the current version from the source each time; forms change without notice.
Verification of Treatment by Attending Physician or Other Provider of Health Service
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
The form says it must reach the insurer as soon as reasonably possible and no later than 45 or 180 days after the treatment date, depending on the policy endorsement in effect at the time of the accident. Under Regulation 68, the 45-day limit applies unless written proof gives clear and reasonable justification for missing it. The claims representative can confirm which limit applies.
No. The form is printed 'not for verification of hospital treatment.' Hospitals report on the NF-4, Verification of Hospital Treatment, and the NF-5, Hospital Facility Form. The NF-3 is for attending physicians and other non-hospital providers of health service, including chiropractors, physical therapists, acupuncturists and psychologists.
Item 20 is an authorization to pay benefits: the insurer pays the provider directly, but the patient keeps all rights under the no-fault law. Item 21 is an assignment of no-fault benefits signed by both patient and provider, in which the provider certifies it has received no payment and will not pursue the patient. Only one of the two may be chosen.
No. Regulation 68 accepts an assignment executed on item 21 of the NF-3, on the NF-4 or NF-5 for hospitals, or on the separate NF-AOB form. The assignment wording is mandatory and may not be changed. The insurer may ask in writing for the original signed assignment or authorization to establish proof of claim.