This form is an Assignment of Money Due. The assignor agrees to grant to the assignee all title and interest in a certain debt or money due as described in the agreement. The form also provides that it is the responsibility of the assignor to collect the debt.
Assignment Due Form For Benefits In Georgia
Category:
State:
Multi-State
Control #:
US-00422
Format:
Word;
Rich Text
Instant download
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The model policy form template for Plans C and D are designated as Form GHBAS-1, and the schedule of benefits for Plans C and D is designated as Form GHBAS-S. You must carefully complete the necessary sections on this form.Insured's ID Number. (Patient's Medicare Health Insurance Claim Number - HICN). The DD Form 1172-2 shall be used to apply for issuance of a DD Form 2 (Reserve, Retired, and. Certain forms must be given to all applicants. Other forms are required based on the program(s) being applied for.
