NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ASSIGNMENT OF BENEFITS FORM

(FOR ACCIDENTS OCCURING ON AND AFTER 3/1/02)
these forms
I,______________________, ("Assignor") hereby assign to Catskill Rehabilitation & Sports Medicine, ("Assignee")
     (Print patient's 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 motor vehicle accident which occurred on __________________, not withstanding any other agreement to the contrary.                                                                     (Print accident date)

This agreement may be revoked by the assignee when the 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 INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, 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 STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.


______________________________________________   ____________________________________________
 (Print name of Patient)
  
(Signature of Patient)
     
______________________________________________   ____________________________________________
   
(Date of signature)
______________________________________________    
(Address)
    
     
     
     
  Barry Scheinfeld, MD   ____________________________________________
(Name of Provider)  
(Signature of Provider
     
  P.O. Box 426   ____________________________________________
  Harris, NY 12742  
(Date of signature)
  (Address)    





NYS FORM NF-AOB (5/2003)

03-00414NFAOB

 


We have been submitting, on your behalf, to your no-fault carrier for charges incurred as a result of your motor vehicle accident. In the event there is any portion of the charges that will not be covered under your car insurance policy and there is no other insurance that will pay these charges, there may be a portion that is unpaid at the time your treatment is terminated.

Therefore, in order to guarantee payment of your medical bill, we are requesting that you authorize your attorney to deduct the full amount of your unpaid bill from the amount you obtain in settlement of your auto accident case and forward that amount to us directly. By signing this letter, you will be authorizing your attorney to do so. If you agree, please sign your name at the bottom of this letter and provide the name and address of your attorney and the date of your accident.

I HEREBY AGREE TO HAVE MY ATTORNEY DEDUCT THE UNPAID MEDICAL BILL DUE YOUR OFFICE FROM THE SETTLEMENT OF MY AUTO ACCIDENT CASE AND FORWARD THE AMOUNT DIRECTLY TO YOU.



X_____________________________________________________________________



My attorney's name and address is:____________________________________________________

____________________________________________________

____________________________________________________


         Date of Accident: __________________________________________










14 HARRIS BUSHVILLE RD. PO BOX 426 HARRIS, NY 12742 • TEL 845-794-0209 • FAX 845-794-0716