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NY No-Fault Assignment of Benefits Form NF-AOB

With this one-page form, a patient injured in a New York motor vehicle accident assigns no-fault benefits to the hospital or health care provider, so the auto insurer pays the provider directly. In return, the provider certifies it has received no payment from the patient and will not pursue the patient for accident-related services. It applies to accidents on and after March 1, 2002, and goes to the insurer with the NF-3 or NF-4 claim.

Who completes it

The patient (assignor) and the hospital or health care provider (assignee) both print their names, sign, date and give an address. The assignment text also needs the patient's name, the provider's name and the accident date printed in its blanks.

How to fill it in

Assignment ("Assignor" and "Assignee")

The opening paragraph names the patient as assignor and the hospital or health care provider as assignee, each printed in the blanks. The patient assigns all rights, privileges and remedies to payment for health care services the assignee provides, to which the patient is entitled under Article 51 of the Insurance Law, the no-fault statute. Under Regulation 68, benefits for other necessary expenses can no longer be assigned for accidents on or after April 5, 2002.

Assignee certification and accident date

The assignee certifies it has not received any payment from or on behalf of the assignor and will not pursue payment directly from the assignor for services provided for injuries from the motor vehicle accident, notwithstanding any other agreement to the contrary. Print the accident date in the blank in this paragraph. Confirm that nothing has been collected from the patient for these services before signing, since the certification says no payment was received.

Revocation by the assignee

The assignment may be revoked by the assignee when benefits are not payable because of the assignor's lack of coverage and/or a violation of a policy condition due to the assignor's actions or conduct. Regulation 68 adds that the patient may not unilaterally revoke it for services already rendered; if revoked for services not yet rendered, the patient must notify the insurer in writing that the provider was told.

Fraud warning

The form carries New York's standard insurance fraud statement: any person who knowingly and with intent to defraud files a claim containing materially false information, or conceals material facts to mislead, commits a fraudulent insurance act, which is a crime and is also subject to a civil penalty for each violation. The same warning appears on the NF-3.

Patient and provider signature blocks

The patient prints a name, signs, dates and gives an address. The provider prints its name, signs, dates and gives its address. Both signatures are needed for a properly executed assignment, which Regulation 68 lists as one way a provider qualifies for direct payment from the insurer. Keep the signed original available, because the insurer may request it in writing to establish proof of claim.

Common mistakes

  • Changing or adding to the assignment wording; Regulation 68 allows only nonsubstantive enhancements on an equivalent form, with no change to the assignment language itself.
  • Accepting payment from or on behalf of the patient for the same accident-related services, which contradicts the provider's certification that none was received.
  • Leaving the accident date, the patient's name or the provider's name blank in the assignment paragraph.
  • Having only the patient sign; the assignee's printed name, signature, date and address are part of the same form.
  • Executing both an authorization to pay benefits (NF-3 item 20) and an assignment; the NF-3 says a patient who chooses one may not also enter into the other.

Submitting and payment

How to submit it
Submit the signed NF-AOB to the insurer with the NF-3 or NF-4 claim and keep the original on file. Regulation 68 lets the insurer request the original in writing to establish proof of claim.
Who pays
There is no fee for the form; under the assignment the insurer pays the provider directly at the no-fault fee schedules, and the provider agrees not to collect from the patient for accident-related services.

Good to know

  • The assignment language is mandatory. Regulation 68 accepts the NF-AOB or an equivalent form with nonsubstantive enhancements, but no changes may be made to the assignment wording itself.
  • A separate NF-AOB isn't needed when the patient and provider sign the same assignment in item 21 of the NF-3, or on the NF-4 or NF-5 for hospitals.
  • The patient cannot unilaterally revoke the assignment for services already rendered. The provider may revoke it when benefits are not payable because of the patient's lack of coverage or a policy violation.
  • For accidents on or after April 5, 2002, benefits for other necessary expenses can no longer be assigned, so the assignment covers payment for health care services.

Get the official form

Download the current version from the source each time; forms change without notice.

Assignment of Benefits Form (for accidents occurring on and after 3/1/02)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What is the difference between the NF-AOB and an authorization to pay benefits?

An authorization to pay benefits, item 20 on the NF-3, lets the insurer pay the provider directly while the patient keeps all rights under the no-fault law. The NF-AOB transfers the patient's rights to payment for the provider's services, and the provider certifies it will not pursue the patient. A patient chooses one or the other, not both.

Can a patient revoke a no-fault assignment of benefits?

Not for services already rendered. Regulation 68 says the assignor may not unilaterally revoke the assignment after those services were provided; if it is revoked for future services, the patient must tell the insurer in writing that the provider was notified. The form separately lets the provider revoke it when benefits are not payable because of the patient's lack of coverage or a policy violation.

Can the provider bill the patient after an NF-AOB is signed?

Not for the accident-related services it covers. The provider certifies it has received no payment from or on behalf of the patient and will not pursue payment directly from the patient, notwithstanding any other agreement. DFS fee schedule guidance adds that providers may not balance bill above the no-fault schedule or pursue the patient after a denial based on an independent medical examination.

Can a practice use its own version of the NF-AOB?

Yes, within limits. Regulation 68 accepts the prescribed NF-AOB or an equivalent form containing nonsubstantive enhancements, but no changes may be made to the assignment language itself. The NF-AOB also states that its language is mandatory and may not be altered or avoided by any other agreement.