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Get Ubmd Orthopaedics & Sports Medicine Frm003.02-ak 2018-2024

/02) Claim Number: 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.

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