If you are unsure of the applicable time requirement, kindly contact the claim representative to determine which deadline is applicable to this claim.
Authorization to pay benefits: if you have chosen to authorize the direct payment of benefits, you may not also enter into an assignment of benefits contained in item B.
Optional agreement: the health provider's agreement to accept payment directly from your insurer is optional and must be signed by both patient and health provider.
Assignment of benefits: if you and your health provider agree to it, you must both sign the agreement contained in item B or the prescribed NF-AOB form or its equivalent.
| Question | Answer |
|---|---|
| Form Name | NYS Form NF-5 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 58 |
| Avg. time to fill out | 10 min |
| Edition | Rev 6/2013 |
| Filing deadline | No later than 45 days or 180 days after treatment date, depending upon the policy endorsement in effect at the time of the accident |
| Other names | NF-5, NF5, NYS Form NF-5, NF-5 form, no fault form, no-fault form, New York no-fault hospital facility form, Hospital Facility Form, New York Motor Vehicle No-Fault Insurance Law Hospital Facility Form |
| Official source | NYS Form NF-5 (Rev 6/2013), New York State Department of Financial Services |
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