Our mission is to provide assistance to injured employees with their workers’ compensation benefits. The below resources will assist you in your communication with our internal team and provide you the necessary forms needed to obtain your benefits.
For additional assistance, please reach out to your assigned adjuster. If you do
not know who that is, please email firstname.lastname@example.org for assistance.
New Claim Forms Packet
The Packet consists of required New York State Workers’ Compensation forms to be filled out by the injured employee.
- New Claim Forms Packet with Optum PBM
- Dear Injured Worker Letter
- Workers’ Compensation Board Intro Letter
- Receipt for Employee Information Packet
- C-3 Form (“Employee Claim”).
- Instructions for Completing Form C-3 (“Employee Claim”)
- C-3.3 Form (“Limited Release of Health Information”)
- Statement of Rights.
- HIPAA Release
- Direct Deposit
- PT & Diagnostic Information Cards
- DT-1 Notice
- First Fill information Optum
Direct Deposit Form
This form allows you to receive your indemnity (lost wage) benefits directly deposited into up to two of your bank accounts, as long as it is over $25.
Mileage and Transportation Form
Use this form to request reimbursement for mileage and transportation costs incurred while obtaining medical treatment.
Physical Capabilities Form
Use this form to gather information from your treating provider to assist in the return-to-work process.
This link will take you to the Workers’ Compensation Board Website to assist in finding a medical provider for your workers’ compensation claim: Find A Provider