Assignment Of Benefits Form printable pdf download

New York Motor Vehicle No-Fault Insurance Law

Assignment of Benefits Form

I, ______________________, (“Assignor”) hereby assign to Select Care Chiropractic, PC (“Assignee”) all

(Print patient’s name)

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 the motor vehicle accident which occurred on________________, not

withstanding any other agreement to the contrary.

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 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 and

application for commercial insurance or a statement of claim for any commercial or personal insurance benefits

containing any materially false information, or conceals for the purpose of misleading, information concerning

any fact material thereto, and any person who, in connection with such application or claim, knowingly makes

or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction,

damage or conversion of any motor vehicle to a law enforcement agency, the department of Motor Vehicles or

an Insurance Company, 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 value of the subject motor vehicle or stated claim for each

violation.

________________________________________

__________________________________________________

(Print name of Patient)

(Signature of Patient)

Sloane DeLuke Eusebio, DC

__________________________________________________

Select Care Chiropractic, PC

(Signature of Provider)

(Provider and Facility Name)

Assignment Of Benefits Form