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 MI
Last
Addr
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