PDF-Assignment of Benefits

DOH 4316 1011 N EW Y ORK S TATE D EPARTMENT OF H EALTH U NINSURED C ARE P ROGRAMS Empire Station PO BOX 2052 Albany NY 122 20 0052 Name ADAP ID 5 5 5 First

insurance benefits care company benefits insurance company care health uninsured address number policy programs state phone information year day

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