Workers' comp reports and OnBoard requests, disability and Paid Family Leave, no-fault, DMV, MOLST and the other New York forms clinicians complete, by program.
New York's forms come from the Workers' Compensation Board, the DMV, the Department of Financial Services, the Department of Health and New York City agencies. Clinicians meet these most: Part B of the DB-450 for disability benefits, the PFL-4 for Paid Family Leave, the NF-3 no-fault verification of treatment, the MOLST (DOH-5003), and the Board's medical narrative and prior authorization requests. This page lists all 71 New York forms, grouped by program.
Most of the old C-4 workers' comp reports were retired in 2022. Now a narrative report goes with every CMS-1500, and prior authorization requests are made online in OnBoard, with no paper option. Return the DB-450 to the claimant within 7 days; the claimant files it with the employer's carrier. Deaths outside New York City are certified in DAVE, and deaths in the city in NYC eVital. Spanish versions exist for 5 of these forms, including the DB-450 and PFL-4.
Medical report that must accompany every CMS-1500 bill, stating work status, causal relationship and temporary impairment percentage, with the narrative of exam findings attached.
Requests approval of a medication not on the NY Workers' Compensation Drug Formulary (including medical marijuana) or otherwise needing prior authorization.
Requests approval of treatment or testing that varies from the NY Medical Treatment Guidelines.
Requests approval of durable medical equipment under the Official NY Workers' Compensation DME Fee Schedule.
Optional request to confirm that treatment consistent with the Medical Treatment Guidelines will be paid.
Requests authorization for special services addressed by the Medical Treatment Guidelines (e.g. surgery-level services) that require prior approval.
Requests authorization for treatment of body parts/conditions not covered by the Medical Treatment Guidelines costing over $1,000.
Treating provider's opinion on maximum medical improvement, schedule loss of use and non-schedule permanent impairment, and functional capabilities, using the 2018 and 2012 impairment guidelines.
Cover sheet and certification for the narrative report of an independent medical examination requested by the carrier/employer or claimant.
IME findings on permanent partial disability of scheduled body parts (schedule loss of use).
Requests authorization for non-MTG treatment costing $1,000 or less.
Physician's certification of the cause of death and whether the work accident or injury caused or contributed to it, for death benefit claims.
Records audiometric test results and calculates percentage hearing loss for occupational loss of hearing claims under WCL Section 49-gg.
Reports the results of a functional capacity evaluation requested by the carrier/employer or attending physician after maximum medical improvement.
Independent examiner's report, required by WCL Section 137, of any request for information received about an IME and of the response given.
IME-4.3BIME findings on non-schedule permanent partial disability (impairment classification and severity) and functional capacity.
Report of a Board-designated impartial specialist's examination or record review.
Impartial specialist's records review, requested by the Board, of a treatment or procedure that needs pre-authorization under the Medical Treatment Guidelines.
Notificación y prueba de reclamo por beneficios por discapacidad
Documents diagnosis, symptoms, objective findings, hospitalization and the period the claimant is unable to work for New York statutory short-term disability benefits (DBL).
Certificado de Proveedor de Atención Médica para el Cuidado de un Miembro de la Familia con un Problema de Salud Grave
Certifies that the employee's family member has a serious health condition and needs the employee's care, with the expected duration and frequency, for New York Paid Family Leave.
Applicant's physician certifies symptoms, diagnosis, treatment, prognosis and that the member is physically or mentally incapacitated for duty, for the TRS Medical Board's review of an ordinary or accident disability retirement application.
Treating physician certifies diagnosis, cause, objective and subjective evidence, treatment and expected return to full duties for the NYCERS Medical Board's review of a disability retirement application.
RET-54.3Physician states dates of treatment and onset and whether the member is totally and permanently disabled from all gainful employment, with a narrative of history, treatment, diagnosis and prognosis, for NYSTRS disability retirement.
Driver's clinician reports medical, physical or mental conditions (epilepsy, syncope, diabetes, sleep disorder, dementia, heart condition, stroke, etc.) and whether they interfere with safe driving, for DMV Medical Review.
MV-619Provider records a vision test for license renewal by mail/online when the provider is not enrolled in DMV's Vision Registry.
Physician, PA or NP reports a person whose driving ability may be affected by a physical or mental impairment, with an opinion on whether privileges should be suspended.
Medical examiner's biennial/initial exam of a bus driver subject to Article 19-A (school and other bus carriers) under 15 NYCRR 6.10: history review, vision, BP, urinalysis, physical exam.
Short statement from the driver's clinician confirming examination, medications, any loss of consciousness or body control, and an opinion on driving ability.
Eye examiner reports acuity and fields for the Low Vision Program (corrected vision 20/40-20/70) or telescopic lens wearers, including bioptic training certification.
Certifies a qualifying disability (hearing, vision, ambulatory, cognitive, other physical, or serious mental illness with SSI) so the applicant gets a Reduced-Fare MetroCard/OMNY benefit on MTA subway, bus and commuter rail.
Medical professional certifies a temporary or permanent severe disability (VTL 404-a) for a local parking permit or DMV license plates with the International Symbol of Access.
Medical professional certifies a permanent severe disability that also limits hand control, reach or meter access, for a metered parking waiver.
Prescribed no-fault claim form on which a treating physician or other non-hospital provider verifies diagnosis, causation, disability (unable-to-work dates), future treatment and services rendered so the auto insurer can pay basic economic loss benefits.
Prescribed assignment by which the patient assigns no-fault benefits to a hospital or health care provider, and the provider certifies it has received no payment from the patient and will not pursue the patient directly.
Standard prior authorization request for prescription drugs covered by NYRx for all New York Medicaid members, including those in managed care.
Medical practitioner certifies the mode of non-emergency transportation (e.g., taxi/livery, ambulette, stretcher) a Medicaid enrollee needs, registering it in the MAS system.
Worksheet prescribers use to prepare the enteral formula prior authorization they submit on the Enteral PA portal or IVR.
Treating provider describes diagnoses, findings and remaining functional capacity so the State Disability Review Unit can decide Disability Medicaid for applicants without an SSA determination.
Establishes the enrollee's need for Medicaid transportation to care available only outside the common medical marketing area.
Documents the physical examination required for new entrants and students in grades pre-K/K, 1, 3, 5, 7, 9 and 11, sports participation, working papers and CSE/CPSE.
Optional certificate a school may request showing a dental health assessment within the past 12 months (Education Law 903).
Physician statement of a medical exemption from New York school and child care immunization requirements (outside New York City), reviewed by the school under NYSDOH procedures.
Publication 4850NYSDOH asthma action plan (green/yellow/red zones) for patients and families, used with the NYS Guide for Asthma Management in Schools.
DOH-4456Medical documentation required by 7 CFR 246.10(d) for WIC to issue exempt infant formula, WIC-eligible nutritionals or non-contract formula, and to modify WIC foods, for a participant with a qualifying medical condition.
DOH-799Referral to WIC with the provider's anthropometric and lab data (height/length, weight, hemoglobin) and nutrition-risk information, used to certify the patient for WIC.
Portable medical order documenting CPR/DNR, intubation (DNI) and other life-sustaining treatment decisions that all providers must follow across care settings; the only authorized NY form for a nonhospital DNI order.
Electronic system (formerly EDRS) used to register and medically certify deaths and fetal deaths occurring in New York State outside New York City.
Electronic system in which NYC medical facilities and certifiers report deaths and certify cause of death for New York City death certificates.
Standard out-of-hospital DNR order that EMS and other providers must honor for a person outside a hospital.
Attending physician's mandatory report to NYSDOH of each prescription written under the Medical Aid in Dying Act (patient, attending, consulting physician, mental health professional and medication details).
Two-physician (or physician + psychiatric NP) certification packet for involuntary hospital admission under Mental Hygiene Law §9.27, plus a request for police custody/transport.
Documents a hospital staff physician's finding that a person needs immediate involuntary inpatient care because of a mental illness likely to result in serious harm, and a staff psychiatrist's confirmation for retention beyond 48 hours.
Mental Hygiene Law §9.37 admission initiated by a county Director of Community Services or a physician designee, with hospital psychiatrist examinations within 24 and 72 hours.
Report of court-ordered psychiatric/psychological examination of a juvenile respondent's capacity to understand the proceedings and assist in their defense (Family Court Act §322.1).
Documents the examining physician's finding and staff psychiatrist's confirmation for involuntary emergency admission to a Comprehensive Psychiatric Emergency Program (up to 72 hours).
Registered practitioner certifies that a patient is likely to receive therapeutic or palliative benefit from medical cannabis so the patient can register and obtain a registry ID.
Physician/provider report of a suspected or confirmed communicable disease (10 NYCRR 2.10) to the local health department of the patient's county.
Report of Suspected Child Abuse or Maltreatment (LDSS-2221A-S)
Mandated reporter's signed written report following an oral report to the Statewide Central Register (SCR) of Child Abuse and Maltreatment.
Provider report of reportable diseases and conditions (incl. HIV/AIDS, STIs, TB infection, hepatitis, lead and poisonings) for New York City residents.
Registers a household member who depends on life-support equipment and certifies a medical emergency so Con Edison applies HEFPA shut-off protections and outage priority.
Medical professional chooses Life Support (electric life-sustaining equipment; meter tag and outage outreach) or Medical Emergency (30-day termination hold, extendable) protection for a household under New York HEFPA.
Physician certifies on page 2 that a taxpayer who retired on disability was permanently and totally disabled, so the taxpayer can exclude disability pay from New York State, NYC and Yonkers income tax.
Physician certifies a resident's permanent physical impairment and how a home improvement accommodates it so the local assessor can exempt the added value of accessibility improvements (RPTL 459).
Physician certifies a crime victim's permanent physical impairment and how a home improvement accommodates it for the RPTL 459-b partial exemption.
Physician certification of a permanent or temporary disability so the hunter may use a longbow with a mechanical device to draw, hold or release the string.
Licensed physician certification that a hunter is non-ambulatory, for a 5-year permit to hunt from a stationary motor vehicle.
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.
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The patient's health care provider: a physician, chiropractor, dentist, podiatrist, psychologist, nurse-midwife, NP or PA. Part B records diagnosis, symptoms, objective findings, hospitalization and the period the claimant cannot work. Return the form to the claimant within 7 days. The claimant files it with the employer's disability carrier, or the Board if the employer is uninsured, within 30 days. Carriers often use their own form but must accept the DB-450. It comes in Spanish and 11 other languages.
Online, through OnBoard in the Board's Medical Portal; paper requests are not accepted. Choose the request type: Medication (drugs not on the formulary, including medical marijuana), DME, MTG Confirmation, MTG Variance, MTG Special Services, or non-MTG treatment above or below the cost threshold. Staff may draft a request, but only the Board-authorized treating provider submits it. The claim administrator answers medication and DME requests within 4 calendar days.
The NF-3, Verification of Treatment by Attending Physician or Other Provider of Health Service. Complete items 1 to 19 (diagnosis, causation, disability, future treatment, services rendered) and sign page 3. The patient signs items 20 and 21 to authorize direct payment or assign benefits, with the assignment on the NF-AOB. Send it to the auto insurer as soon as reasonably possible, no later than 45 or 180 days after treatment depending on the policy. Hospitals use the NF-4 and NF-5.
A physician, nurse practitioner or physician assistant; for patients with intellectual or developmental disabilities under SCPA 1750-b, only a physician. The practitioner completes the form with the patient or decision-maker and signs sections B, C and F to H. The original stays with the patient. Any color paper works, and the electronic eMOLST is also accepted. The MOLST is the only New York form for a nonhospital DNI order; the DOH-3474 covers DNR only.