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(If Known) CLAIMANT CARRIER CASE NO - wcb ny

(If Known) CLAIMANT CARRIER CASE NO - wcb ny 2026

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This document is a notice informing the claimant that they may be responsible for medical costs related to their injury or illness if they fail to prosecute their workers' compensation claim, if the claim is denied, or if they enter into a Section 32 agreement waiving future medical benefits. It outlines the circumstances under which the healthcare provider may bill the claimant directly and emphasizes the importance of understanding personal liability for medical expenses.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the WCB Case Number (If Known) at the top of the form. This is crucial for tracking your claim.
Fill in the Claimant's name and address, ensuring all details are accurate to avoid any processing delays.
Input the Date of Injury and Nature of Injury or Illness. Be specific as this information is vital for your case.
Provide the Injured Person’s Social Security Number and Employer Insurance Carrier details. Double-check these entries for correctness.
Finally, sign and date the form at the bottom, acknowledging your understanding of potential medical cost responsibilities.

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