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NF-AOB (Rev 1/2004) Assignment of Benefits Form-2025

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The document is an Assignment of Benefits Form under the New York Motor Vehicle No-Fault Insurance Law, allowing a patient (Assignor) to assign their rights to payment for healthcare services related to a motor vehicle accident to a healthcare provider (Assignee). It includes provisions regarding the certification of non-payment by the Assignee and outlines penalties for fraudulent claims.

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Click ‘Get Form’ to open the NF-AOB (Rev 1/2004) Assignment of Benefits Form in our platform.
In the first section, enter the name of the Assignor (the patient) and the Assignee (the healthcare provider). Make sure to print clearly for accurate processing.
Next, fill in the date of the accident. This is crucial for establishing the context of your claim under Article 51 of the No-Fault statute.
The Assignee must certify that they have not received any payment from or on behalf of the Assignor. Ensure this section is completed accurately to avoid any issues with claims.
Both parties need to provide their signatures along with printed names and addresses. This confirms agreement and understanding of the assignment terms.
Finally, review all entered information for accuracy before saving or exporting your completed form. Our editor allows you to make adjustments easily.

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What is the AOB assignment of benefits form?

This Assignment of Benefits (AOB) form is used to assign benefits directly to your provider. * Once your plan of care has been established, you may submit the completed form. Your provider must also complete and submit the attached W-9 form. Only one AOB form and one W-9 form are required per provider per claim.

What are the rules for no-fault billing in NY?

Under New York no-fault insurance law, each injured victim of an auto accident is entitled to payment for certain first party benefits. These benefits include all medical expenses up to a limit of $50,000 and lost wage benefits for up to three years.

What are the first party benefits of the no-fault law in NY?

First Party Benefits. This is the core coverage under the New York no-fault law that provides up to $50,000 for basic economic loss to persons injured in or by an insured vehicle.

Who pays for car damage in a no-fault state New York?

New York is a no-fault insurance state, but those laws apply only to injuries in a car accident and not to claims for vehicle damage. Within certain limits, reimbursement is the responsibility of the driver who caused the accident and their insurance.

How long do you have to file a no-fault claim in NY?

You must file a no-fault application within 30 days of the accident; You must submit medical bills to the no-fault carrier within 45 days of treatment; and. Other expenses, such as lost wages and out-of-pocket costs, must be submitted within 90 days of being incurred.

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What is no-fault billing in NY?

No-Fault coverage can vary depending on the exact coverage of your policy. In New York, the mandatory minimum No-Fault coverage all drivers must carry is $50,000. Thus, your No-Fault coverage will pay for the combined total of your medical bills, lost wages, and other reasonable and necessary expenses up to $50,000.

What is an assignment of benefits form for?

Understanding AOB The answer is simple. This form gives the insurance company written authorization to release information that the hospital requires for reimbursement purposes. It also allows medical billing and collection companies to use that information for their billing purposes.

NF-AOB (Rev 1/2004) Assignment of Benefits Form-2025

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What is the AOB assignment of benefits form?

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Who pays for car damage in a no-fault state New York?

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