Nys Form Nf Aob PDF Details

In the bustling state of New York, where the streets are as busy as the state of mind of its residents, motor vehicle accidents are, unfortunately, a commonplace event. With these incidents comes the complex world of insurance claims, a realm filled with paperwork and technicalities aimed at ensuring victims receive the medical attention and compensation they deserve. At the heart of this process lies the New York Motor Vehicle No-Fault Insurance Law Assignment of Benefits Form, colloquially known as the NYS NF-AOB form, which plays a critical role in the financial dynamics between healthcare providers, patients, and insurance companies for accidents occurring on and after March 1, 2002. This form allows a patient, referred to as the "Assignor", to transfer their rights, privileges, and claims for payment under the No-Fault statute of the Insurance Law to their healthcare provider, or "Assignee", ensuring providers can directly bill insurance companies for the services rendered. It's a mechanism designed to streamline payments and alleviate financial stress from the patient, contingent upon the condition that the healthcare provider does not seek payment from the patient for services covered by no-fault benefits. Additionally, this form encapsulates a stern warning against insurance fraud, highlighting the severe repercussions for such acts, thus ensuring all parties engage in these transactions with integrity and responsibility.

QuestionAnswer
Form NameNys Form Nf Aob
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform aob no fault, new york state no fault assignment of benefits form, nys form nf aob, no fault assignment of benefits form

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NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW

ASSIGNMENT OF BENEFITS FORM

(FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02)

I,

 

, ("Assignor") hereby assign to

 

, ("Assignee")

 

(Print patient's name)

 

(Print hospital or health care provider 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 the motor vehicle accident which occurred on

, not withstanding any other agreement

(Print accident date)

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 AN 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)

(Date of signature)

(Address of Patient)

(Print name of Provider)

 

(Signature of Provider)

(Date of signature)

(Address of Provider)

NYS FORM NF-AOB (Rev 1/2004)

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