This form is used to obtain the signature of someone legally able to assign benefits when the individuals who sign the application do not have the right to do so.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (42 kb pdf)

E-Forms are presented in Adobe Acrobat and require the Adobe Acrobat reader. If you do not currently have Adobe Acrobat reader installed, you may download a free copy by clicking the Get Adobe Reader icon below.

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Axiom
North Dakota
Manual
HHS
ACA Medicaid
510 03 100 55
Block 1

SFN 560, "Assignment of Benefits" 510-03-100-55

Official source

(New 7/1/2014 ML #3404)

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This form is used to obtain the signature of someone legally able to assign benefits when the individuals who sign the application do not have the right to do so.

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms . (42 kb pdf)

in view

Whole section