No Fault Benefits Form printable pdf download

No Fault Benefits Form

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW

ASSIGNMENT OF BENEFITS FORM

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

I, ______________________________(“Assignor”) herby assign to Cayuga Orthopaedic

(Print Patients Name)

and Sports Physical Therapy P.C. (COAST Physical Therapy) (“Assignee”) all rights and

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 the motor vehicle accident which occurred on

___________________________, not withstanding any other agreement to the contrary.

(Print

Date of the Accident)

This agreement may be revoked by the assignee when benefits are not payable based upon the

assignor’s lack of coverage and/or violation of a policy due to the actions or conduct of the

assignor.

ANY PERSON WHO NOWINGLY 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 CANCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING

ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURNACE 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

Print name of Provider

Signature of Provider

Date of Signature

Address

Over 

NYS FORM NF-AOB (5/2003)

No Fault Benefits Form