No Health Insurance Form
Date:
Patient Name: I, , am not now eligible under any group health, sickness or disability insurance as of (date). If I become eligible during the 2 years following the date of my accident or injury, I will notify my PIP insurance carrier: . “Any person who knowingly and with intent to defraud any insurance company or other person, files a statement of claim containing any materially false information, may be subject to criminal prosecution and civil penalties.” | 
