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No Fault

• Request For No-Fault Mileage Reimbursement  (PDF)
• Request For No-Fault Reimbursement of Household  Services  (PDF)
• NF 1A – No Fault Cover Letter (PDF)
• NF 1A – Application For NY Motor Vehicle No-Fault Benefits (PDF)
• NNF 1A – Employer’s Wage Verification Report Form (PDF)
• NF 7 – NY Motor Vehicle No-Fault Insurance Law Verification of Self-Employment Form (PDF)
• NF 8 – Agreement To Pursue Social Security Disability Benefits (PDF)
• NF 11– Additional PIP Sub Agreement (PDF)

Motor Vehicle 

• MV 104 Accident Report (PDF)
• Accident Report Key (PDF)

Misc

• DB450 – Notice and Proof of Claim For Disability Benefits (PDF)
• SSA – 3288 – Social Security Consent for Release of Information (PDF)
• CMS 10106 – Medicare Authorization To Disclose Personal Health Information (PDF)
• Medicare Proof of Representation (PDF)
• DOH-5198 – Authorization To Release Protected Medicaid Member Information To a Third Party (PDF)
•  4506 – Request For Copy of Tax Return (PDF)
• SF95-07a – Claim For Damage, Injury or Death Form (PDF)

Office Forms

• Before Your First Visit: Check List (Call Our Office)
• What To Expect During Your IME (Call Our Office)
• Privacy Policy
• Form 960 – Authorization For Release Of Health Information Pursuant To HIPPA (PDF)
• ​NYS SUM / UM Demand for Arbitration (PDF)
• New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form (PDF)
• Complaints about New York State Hospitals and Diagnostic and Treatment Centers (Link to Off-Site Contact Form)
• DOH-3867 – Office of Professional Medical Conduct Doctor Complaint Form