This form is used to obtain the signature of someone legally able to assign benefits when the individuals who signs 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
Medicaid
510 05 100 05
Block 1

SFN 560, "Assignment of Benefits" 510-05-100-05

Official source

(Revised 6/01 ML #2590)

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This form is used to obtain the signature of someone legally able to assign benefits when the individuals who signs 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