Get Ny Himp-1 2018-2025

The NY HIMP-1 form is an essential document for health insurers and health benefit plans requesting reimbursement for payments made on behalf of injured workers. This guide provides clear, step-by-step instructions on how to accurately complete this form online.

Follow the steps to complete the NY HIMP-1 form effectively.

1. Press the ‘Get Form’ button to access the NY HIMP-1 form and open it in your online editor.
2. Begin filling out Part I by entering the claimant’s name, WCB case number, social security number, date of accident, employer's name, WC carrier case number, and WC carrier code.
3. Specify the reimbursement amount requested and the date of full or partial match, if applicable. Indicate whether an ANCR was established, fill in the date payment was made, and include the health insurer's claim ID number if previously filed for this case.
4. Provide the name and address of the WC insurance carrier/employer/special fund, and the status of the case (open or closed).
5. Next, fill in the health insurer's information including the name, address, federal tax ID number, email contact, and telephone number. If applicable, provide the HIMP agent's details.
6. In the printed name field, sign and date the form to certify the request for reimbursement, indicating your title.
7. If the WC insurance carrier/employer/special funds has any objections, they will need to complete Part II of the form, specifying the reasons for any objections and attaching supporting documentation.
8. For requests for arbitration, complete Part III, including the AAA case number, specifying whether you are requesting desk arbitration or an oral hearing, and include the arbitration fee if applicable.
9. Finally, review your entries for accuracy, save changes, and then download or print the completed form for submission.

Complete your NY HIMP-1 form online today to ensure timely processing of your reimbursement request.