Get And Sign No Insurance Form Hospital

DESCRIBED BELOW. I RETAIN ALL RIGHTS PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER ARTICLE 51 THE NO-FAULT PROVISION OF THE INSURANCE LAW. SIGNED SIGNATURE OF HOSPITAL REPRESENTATIVE provider Assignment of Benefits. If you and your health provider agree to an assignment of benefits you must both sign the agreement contained in item B or the prescribed NF-AOB form or its equivalent. You may use the optional authorization language provided below by checking off the designated spot in item...