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OTHER
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Directory Results for I, , OMB No 1545-0047 990 Return of Organization Exempt From Income Tax 2006 Under section 501 (c), 527 , or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation) Department of vie Treasury to I, , ( Assignor ) hereby assign to, (print patient/client s name) , ( Assignee ) all rights privileges and remedies to payment (print hospital or health care provider name) for health care services provided by the assignee to which I am

I, , OMB No 1545-0047 990 Return of Organization Exempt From Income Tax 2006 Under section 501 (c), 527 , or 4947(a)(1) of the Internal Revenue Code (except black lung benefit trust or private foundation) Department of vie Treasury
I, , ( Assignor ) hereby assign to, (print patient/client s name) , ( Assignee ) all rights privileges and remedies to payment (print hospital or health care provider name) for health care services provided by the assignee to which I am