How to complete DB-450 Part B (New York disability benefits)
DB-450 is New York's claim form for disability benefits. Part B is the health care provider's statement. This guide walks through Part B item by item, in the form's order.
- Form
- Notice and Proof of Claim for Disability Benefits, Part B: Health Care Provider's Statement
- Issued by
- New York State Workers' Compensation Board
- Revision
- DB-450 (10-23)
- Checked against the source
- November 5, 2026
What it is and when it is used
DB-450, the Notice and Proof of Claim for Disability Benefits, is how a New York worker claims disability benefits for a period they cannot work because of an illness or injury.
The form has three parts. The worker fills in Part A, the health care provider fills in Part B, and the employer fills in Part C. The worker passes the form to each in turn.
Part B also asks, in item 8, whether you think the disability came from work.
Who completes which part
| Part | Completed by | What it covers |
|---|---|---|
| Part A | Claimant (the patient) | Personal details, a description of the disability, the date it began, recent employers and wages, and other benefits received. The claimant signs it. |
| Part B | Health care provider | Diagnosis, symptoms and objective findings, hospital stays and operations, treatment dates, the expected return to work date, and whether the disability is work related. |
| Part C | Employer | Business details, the employee's dates and wages, whether wages continued, and the employer's signature. |
The provider's part, section by section
The form says Part B must be filled in completely, and that incomplete answers may delay payment of benefits.
Items 1 to 3: the claimant
The claimant's name, gender and date of birth.
Item 4: diagnosis
The diagnosis and its diagnosis code. Item 4a is the claimant's symptoms. Item 4b is your objective findings.
Items 5 and 6: hospital stay and operation
Item 5 asks whether the claimant was hospitalized, and the dates. Item 6 asks whether an operation is indicated, and its type and date.
Item 7: dates
Five dates, each as month, day and year:
- 7a: your first treatment for this disability.
- 7b: your most recent treatment for it.
- 7c: the date the claimant became unable to work because of it.
- 7d: the date the claimant will be able to work again. The form asks for an estimate even when there is real doubt, and asks you not to write "unknown" or "undetermined".
- 7e: if the disability is related to pregnancy, check the box and give the estimated or actual delivery date.
Item 8: work related or not
Your opinion on whether the disability came from an injury at work or from an occupational disease. If yes, the form asks whether a medical report has been filed with the Workers' Compensation Board.
Your certification
Check your license type from the list on the form (physician, chiropractor, dentist, podiatrist, psychologist or nurse-midwife), then give the state of your license, your license number, your printed name, address and phone. Sign and date it.
Deadlines the form states
- The form says the attending health care provider must complete Part B and return it to the claimant within seven days of receiving the form.
- The form gives the claimant 30 calendar days from the first day of disability to submit the completed claim, and gives the employer three business days to return Part C.
Where it goes
Return the form to the claimant. The form says a claimant who became disabled while working, or within four weeks of leaving a job, sends it to the employer or the employer's disability insurance carrier. Otherwise it goes to the Board's Disability Benefits Bureau.
Official source
DB-450 (10-23). Checked against the issuer's copy on November 5, 2026. This guide paraphrases the form's own instructions; the form and New York State Workers' Compensation Board are the authority.
How Scribeable fills it
Scribeable fills the official DB-450 from your visit note. It writes an answer only when the note states it.
Anything the note does not say stays blank for you to complete. Parts A and C are left for the claimant and the employer. Your signature and the date you sign are always yours to add.
Each filled answer shows the sentence in the note it came from, so you can check it before you sign.
You review every field, then download or print the form, sign it, and return it to the patient.
Other forms
- FMLA, employee (WH-380-E)U.S. Department of Labor, Wage and Hour Division
- FMLA, family member (WH-380-F)U.S. Department of Labor, Wage and Hour Division
- NY workers' comp narrative (CMS-1500 template)New York State Workers' Compensation Board
- CA workers' comp progress report (PR-2)California Division of Workers' Compensation
- FL disabled parking permit (HSMV 83039)Florida Department of Highway Safety and Motor Vehicles
- CA SDI Part B answers (DE 2501)California Employment Development Department
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