EnCare Assignment of Benefits

I

(“Assignor”) hereby assign to EN-CARE, INC. (“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 :

EN-CARE, INC.
4 Court Square, 4th Floor
L.I.C. New York 11101
(Address)

NYS FORM NF-AOB (5/2003)

03-00414NFAOB

Name of Provider :

Date :

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