New York Providers Request For Judgment of Award is a document used by providers in New York State when submitting a claim for payment from an insurance company. This document is used to request a judgment of award from the state Insurance Department, which will require the insurance company to make the payment to the provider. The Request For Judgment of Award must include detailed information about the provider, the claim, and the services provided. There are several types of New York Providers Request For Judgment of Award, including those for medical services, mental health services, and durable medical equipment.
New York Providers Request For Judgment of Award
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Providers Request For Judgment of Award
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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.
To apply for authorization, you must: Sign up to use the NYS Workers' Compensation Board Medical Portal and/or login with the credentials that have been assigned to you; Complete the required training specific to your profession; Complete the New Provider Authorization Request online application.
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.
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