En-Care Home Care
NYS ASSIGNMENT OF BENEFITS
HOME
WORKERS' COMP
REFERRAL FORM
CRIME VICTIM
BROCHURE
CONSENT FORM
NYS ASSIGNMENT OF BENEFITS
PRIVATE POLICY
OUR SERVICES
INSURANCE
CONTACT US
EMPLOYMENT OPPORTUNITIES
HELP US HELP YOU
BILL OF RIGHTS
STAFF DUTIES
MEDICAL MALPRACTICE

NYS Form NF-AOB

En-Care, Inc.

4 Court Square, 4th Floor

L.I.C., New York11101

Phone (212) 594-2334 or (718) 786-6330  Fax (718) 786-6377

 

                      New York Motor Vehicle No-fault Insurance Law Assignment of Benefits Form 

          

  (For Accidents occurring on or after 3/1/02)

 

I,______________________, ("Assignor") hereby assign to EN-CARE, INC. ("Assignee")
       (PRINT PATIENT'S NAME)                                                           
     
all rights, privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of the Insurance Law.

The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to motor vehicle accident which occurred on __________________, not withstanding any other agreement to the contrary.           (Print accident date)


This agreement may be revoked by the assignee when the benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor.



ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.



______________________________________________   ____________________________________________
 (Print name of Patient)
 
(Signature of Patient)
     
______________________________________________   ____________________________________________
   
(Date of signature)
______________________________________________    
(Address)
   
     
     
     
    EN-CARE, INC.   ____________________________________________
(Name of Provider)  
(Signature of Provider
     
  4 Court Square, 4th Floor   ____________________________________________
  L.I.C. New York 11101  
(Date of signature)
  (Address)    






NYS FORM NF-AOB (5/2003)

03-00414NFAOB