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New York DB-450 Part B: Disability Benefits Claim

New York's statutory disability benefits program pays workers who cannot work because of a disability, including pregnancy, and DB-450 is its standard claim form. The attending provider completes Part B with the diagnosis, symptoms, objective findings and the date the claimant can work again. The claimant files the whole form with the employer's disability carrier and should get a response within 18 days.

Who completes it

The attending health care provider completes and signs Part B, the Health Care Provider's Statement. The claimant completes Part A, and the employer completes Part C and must return it to the claimant within three business days.

How to fill it in

Part A - Claimant's Information

The claimant describes the disability and the date it began, lists employers and gross wages for the last eight weeks, and answers questions about unemployment, Paid Family Leave, workers' compensation, no-fault or third-party claims and prior disability benefits, then signs. The instructions tell the claimant to complete Part A and keep a copy before passing the form on.

Part B - Health Care Provider's Statement: items 1 to 4

Enter the claimant's name, gender and date of birth, then the diagnosis or analysis with a diagnosis code. Item 4a asks for the claimant's symptoms and 4b for objective findings. The heading states that the statement must be filled in completely and that incomplete answers may delay payment of benefits, so leave nothing blank that applies.

Items 5 and 6: Hospitalization and operation

Indicate whether the claimant was hospitalized, with from and to dates, and whether an operation is indicated, with the type of operation and its date. Like every item in Part B, these must be answered; the form warns that incomplete answers may delay payment of the claimant's disability benefits.

Item 7: Treatment and disability dates

Enter the date of your first treatment for this disability, your most recent treatment, the date the claimant became unable to work, and the date the claimant will again be able to perform work. The form says to estimate the return date even when considerable question exists and to avoid unknown or undetermined. For pregnancy, check 7-e and give the estimated or actual delivery date.

Item 8: Work-related disability

Give your opinion on whether the disability is the result of an injury arising out of and in the course of employment, or of an occupational disease. If you answer yes, state whether medical reports have been filed with the Board. The claimant answers related questions in Part A about workers' compensation claims.

Provider certification and signature

Certify your provider type (physician, chiropractor, dentist, podiatrist, psychologist or nurse-midwife) and the state where you are licensed or certified, then print your name, address, license number and phone, sign and date. Return the completed form to the claimant within seven days of receipt so they can file it on time.

Part C - Employer Information

The employer enters business details, FEIN, a contact person, union coverage, hire and last-worked dates, wage continuation, whether the disability is work-related, eight weeks of gross wages and prior leave, then signs. It must return the form within three business days, but the carrier cannot deny the claim solely because the employer failed to complete Part C.

Common mistakes

  • Leaving Part B items blank; the form states the statement must be filled in completely and incomplete answers may delay payment of benefits.
  • Writing 'unknown' or 'undetermined' for the return-to-work date in item 7-d instead of giving an estimate, as the form instructs.
  • Returning the form to the claimant more than seven days after receipt, which holds up the claimant's filing with the carrier.
  • Skipping item 7-e for a pregnancy-related disability, where the estimated or actual delivery date is required.
  • Omitting the diagnosis code next to the diagnosis or the objective findings in item 4b, both of which Part B asks for.

Submitting and payment

How to submit it
Return the form to the claimant within seven days of receiving it. The claimant files it with the employer's disability carrier within 30 days of the first day of disability, or with the Workers' Compensation Board's Disability Benefits Bureau if disabled more than four weeks after employment ended.

Good to know

  • Benefits generally start on the eighth consecutive day of disability and run up to 26 weeks in any 52-week period, with disability and Paid Family Leave combined capped at 26 weeks.
  • Carriers often use their own claim forms but must accept DB-450. The Board publishes it in Spanish and 11 other languages, including Russian, Chinese, Haitian Creole, Korean and Bengali.
  • If the disability stems from a no-fault motor vehicle accident or a third party's negligence, the claimant also files DB-450.1; a rejected claim brings Form DB-451 within 45 days.
  • Item 8 asks whether the disability arose out of employment or is an occupational disease, and if so, whether medical reports have been filed with the Board.

Get the official form

Download the current version from the source each time; forms change without notice.

Notice and Proof of Claim for Disability Benefits (Part B - Health Care Provider's Statement)

Notificación y prueba de reclamo por beneficios por discapacidad

Official pagePDFVersión en español

How this list is checked

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.

Frequently asked questions

Who can complete Part B of DB-450?

The certification line lists a physician, chiropractor, dentist, podiatrist, psychologist or nurse-midwife licensed or certified in their state, and the Board's guidance says the claimant must be under the care of one of these providers to qualify. The provider prints their name, address, license number and phone, then signs and dates.

How long does a provider have to complete DB-450?

The form tells the attending provider to complete Part B and return it to the claimant within seven days of receiving it. If the provider is late, the claimant has to wait before filing with the carrier, and incomplete answers may delay payment. The claimant must file within 30 days of the first day of disability.

Is DB-450 available in Spanish?

Yes. The Workers' Compensation Board publishes DB-450 in Spanish as well as Russian, Polish, Chinese, Italian, Haitian Creole, Korean, Bengali, Yiddish, Arabic, French and Urdu. Insurance carriers that send their own claim forms must still accept the Board's DB-450.

What if the return-to-work date is uncertain on DB-450?

Item 7-d asks for the date the claimant will again be able to perform work and says to estimate it even when considerable question exists, avoiding terms such as unknown or undetermined. For pregnancy-related disability, check item 7-e and enter the estimated or actual delivery date.