Form MMC4312 "No Fault Insurance Form - Montefiore" - New York City

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Download Form MMC4312 "No Fault Insurance Form - Montefiore" - New York City

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NO FAULT INSURANCE FORM
PATIENT INFORMATION
NAME: __________________________________
SS #: ______________________________
ADDRESS: ______________________________
BIRTHDATE: ________________________
________________________________________
PHONE #: __________________________
WHAT PART OF THE BODY ARE YOU BEING SEEN FOR TODAY? (PLEASE STATE: RIGHT OR LEFT):
__________________________________________________________________________________
PLEASE LIST ALL BODY PARTS INJURED AT TIME OF ACCIDENT (PLEASE STATE: RIGHT OR LEFT):
__________________________________________________________________________________
__________________________________________________________________________________
INSURANCE COMPANY INFORMATION
INSURANCE CO. NAME: ____________________
CONTACT: __________________________
ADDRESS: ______________________________
PHONE #: __________________________
________________________________________
DATE OF ACCIDENT: __________________
POLICY HOLDER: ________________________
POLICY #: __________________________
ADDRESS: ______________________________
FILE/CLAIM #:________________________
LEGAL REPRESENTATIVE:__________________
ADDRESS: __________________________
PHONE #: ________________________________
__________________________________
AUTHORIZATION
I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS
D
A
THIS CLAIM. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE
_
ORIGINAL.
I HEREBY AUTHORIZE DR.________________________ TO APPLY FOR BENEFITS ON MY
BEHALF FOR SERVICES RENDERED. I REQUEST THAT PAYMENT FROM THE INSURANCE
COMPANY BE MADE DIRECTLY TO DR._____________________________.
I CERTIFY THAT THE INFORMATION THAT I HAVE REPORTED WITH REGARD TO MY
INSURANCE COVERAGE IS CORRECT.
EITHER MY INSURANCE COMPANY OR MYSELF MAY REVOKE THIS AUTHORIZATION AT
ANY TIME IN WRITING.
QOD
U
IU
MS
MS0
.Xmg
4
W
Every other day Unit
International Unit Morphine Sulfate Magnesium Sulfate
Xmg
0.Xmg
_______________________________________ _______________________________________ ______________________
P
N
S
D
/T
RINT
AME
IGNATURE
ATE
IME
MMC4312 (2/13)
NO FAULT INSURANCE FORM
PATIENT INFORMATION
NAME: __________________________________
SS #: ______________________________
ADDRESS: ______________________________
BIRTHDATE: ________________________
________________________________________
PHONE #: __________________________
WHAT PART OF THE BODY ARE YOU BEING SEEN FOR TODAY? (PLEASE STATE: RIGHT OR LEFT):
__________________________________________________________________________________
PLEASE LIST ALL BODY PARTS INJURED AT TIME OF ACCIDENT (PLEASE STATE: RIGHT OR LEFT):
__________________________________________________________________________________
__________________________________________________________________________________
INSURANCE COMPANY INFORMATION
INSURANCE CO. NAME: ____________________
CONTACT: __________________________
ADDRESS: ______________________________
PHONE #: __________________________
________________________________________
DATE OF ACCIDENT: __________________
POLICY HOLDER: ________________________
POLICY #: __________________________
ADDRESS: ______________________________
FILE/CLAIM #:________________________
LEGAL REPRESENTATIVE:__________________
ADDRESS: __________________________
PHONE #: ________________________________
__________________________________
AUTHORIZATION
I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS
D
A
THIS CLAIM. I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE
_
ORIGINAL.
I HEREBY AUTHORIZE DR.________________________ TO APPLY FOR BENEFITS ON MY
BEHALF FOR SERVICES RENDERED. I REQUEST THAT PAYMENT FROM THE INSURANCE
COMPANY BE MADE DIRECTLY TO DR._____________________________.
I CERTIFY THAT THE INFORMATION THAT I HAVE REPORTED WITH REGARD TO MY
INSURANCE COVERAGE IS CORRECT.
EITHER MY INSURANCE COMPANY OR MYSELF MAY REVOKE THIS AUTHORIZATION AT
ANY TIME IN WRITING.
QOD
U
IU
MS
MS0
.Xmg
4
W
Every other day Unit
International Unit Morphine Sulfate Magnesium Sulfate
Xmg
0.Xmg
_______________________________________ _______________________________________ ______________________
P
N
S
D
/T
RINT
AME
IGNATURE
ATE
IME
MMC4312 (2/13)
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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