New York Notice That You May Be Responsible For Medical Costs is a notice that is issued to patients by their health care provider to inform them that they may be responsible for medical costs incurred, even if the costs are covered by insurance. This notice is typically used to inform patients of their potential financial responsibility for services rendered. It is also used to identify any other potential charges, such as co-payments, deductibles, coinsurance, or out-of-pocket expenses. There are two different types of New York Notice That You May Be Responsible For Medical Costs: an “Explanation of Benefits” notice and “Notice of Medical Costs”. The Explanation of Benefits notice explains what portion of the medical costs were covered by insurance, and what portion the patient may be responsible for. The Notice of Medical Costs informs the patient of any additional charges that they may be responsible for.
New York Notice That You May Be Responsible For Medical Costs
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Request for Decision on Unpaid Medical Bill(s) (Form HP-1.0) If an insurance carrier has not paid your bill in full within 45 days of submission, you may be able to request the Board's assistance by filing Form HP-1.0 through OnBoard.
SI-12 (7/09) Affidavit Certifying That Compensation Has Been Secured. Employers with Board-approved self-insurance for workers' compensation. Filed with the government agency issuing a permit, license or contract. The SI-12 must be completed by the Board's Self-Insurance Office and approved by the Board's Secretary.
Accepted Forms: U26.3 ? Certificate of Workers' Compensation Ins (NYS Insurance Fund only)
A detailed narrative progress/supplemental report is filed to document any significant change in the worker's medical or disability status.
If you filed a claim and were assigned a number, you can call (646)264-3000 for information about your claim. If you are a U.S. Department of Labor employee, please call (816)502-0301 for claim status information.