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Fillable NF- AOB Assignment of Benefits Form - State Farm Insurance

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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) Claim Number: 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...
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