EFTA01650840.pdf

9 If the victim was injured or died because of this crime, fill out below. Describe the victims injuries. briefly NN X QLiCIC Act chl`-.), rnfvtc f.-r(1-‘c cu_c__Y r. CEit t eV170.-3, Did the victim receive any medical treatment? 0 Yes J (If No, skip to sectfon10.)77t* gA0 e-c- V-n+ VI S EACri Tell us about the health professionals who treated the victim for injuries related to this crime: Full Name Complete Address Phone X First Hospital Other Hospital First Doctor (riot on hospta0 Other Doctor First Dentist Victim s Counselor 10 Tell us about the victim's dependents or o depended on the victim for support. (IInone, skip to 11 ) Rnl nthIn In Victim Social Secunty atin Dependent •- _ • __ Are you the legal guardian? 0 Yes 0 No Name Social Secunty Date of Binh Relationship to Victim Other Dependent •_ _ • Address Are you the legal guardian? 0 Yes 0 No Name Social Security Date of Birth Relationship to Victim Other Dependent —— Address Are you the legal guardian? 0 Yes 0 No if more Than 3 dependents. attach a separate sheet and check hew 0 11 Did anyone besides the victim receive counseling because of this crime? (If no. skip to 12 ) Who received counseling? Relationship to Victim Insurance company billed for counseling Policy or ID It Counselor's name. address and phone # Who else received counseling? Relationship to Victim Insurance company billed for counseling Policy or ID # Counselor's name, address and phone # If more than 2 people received counseling because of this crime, check here and attach a separate sheet to descnbe 0 12 List any insurance covering the victim or the victim's dependents. If no insurance. write "None" below If you have applied but are not covered yet. write 'Pending' under Policy or ID #. Poen or ID # Alamo ofarson's, myerefl by this incritiner Pnmary Insurance Company Major Medical Insurance Company LLD (Union, Deed& Vision at) I . ._ct-c- Other Insurance Medicare Medicaid Workers' Compensation Auto Insurance gess, 14/.,e_ Other insurance Rev September 2016 Pigs 3 of 4 EFTA01650840  •HIPAA• OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health' Patient Name Date of Binh I or my authorized representative, request that health information regarding my cart and treatment be released asset forth on this form: In accordance with New York State Law and the Privacy Rule of the lkalth Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: I. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes. and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8 2. If I am authorizing the release of HIV-related. akohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my IIIV-related information without authorization. If I experience discrimination because of the release or disclosure of HI V-related information. I may contact the New York State Division of Human Rights at (212) 480- 2493 or the New York City Commission of I luman Rights at (212) 306-7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health can provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. 5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2). and this redisclosure may no longer be protected by federal or state law. 6 THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE. OTHER TITAN THE ATTORNEY V RNMENTAL AGENCY SPECIFIED IN ITEM 9(b). 7. N this information: 8. Name an address o persons or category o person to whom this information will be sent: NYS OFFICE OF VICTIM SERVICES - AE SMITH BLDG., 80 S. SWAN ST., ALBANY, NY 12210-8002 9(a)..Specific information to be released: fii,Medical Record from (insert date) to (insert date) 9Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies. films, referrals, consults, billing records. insurance records, and records sent to you by other health care providers. O Other • • iCtile by Initialing) leohoVDrug Treatment twat Health Information Authorization to Disc Information V-Related Information (b) CI By initialing h • !authorize Initials Name o individual health care provider to discuss my health information with my attorney. or a governmental agency, listed here: NEW YORK STATE OFFICE OF VICTIM SERVICES (Ationieyffirm Name or Governmental Agency Name) I0. Reason for release of information: II. Date or event on which this authorization will expire: At request ofthe individualforpurports ofestablishing This authorization will apart upon the termination ofthe eligibilityfor New Fork State Office of Victim Services individual's eligibility for Office of Victim Services benefits. benefits. 12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient: All itei my questions about thi • form have been answered. In addition, I have been provided a copy of the 1 Dale. ct* -2-Zszs-91 Zorl 'Sign; d by law. • Human Immunodeficiency Virus that causes AIDS. The New York State Public I icanti Taw protects information which reasonably could identify someone as having 111V symptoms or infection awl information regarding a person's contacts. EFTA01650841 13 If the victim died, tell us about any life Insurance and death benefits. (It the victim did not die. or does not have any life insurance or death benefits. skip to 14.) Company Name Address Phone a Policy or ID U Life Insurance Pension Plan ( 1 Other Insurance/Plan f Medicaid f Workers Compensation If any other insurance or death benefits. list here. Do any of these policies cover the victim's burial expenses? ❑ yes 0 No Has anyone applied for the Social Security Death Benefit? 0 Yes 0 No 14 Tell us about your financial situation. You MUST fill out ALL sections below. If none, enter zero (0). How many dependents d0 you have? What is your total annual income (from ALL sources)? If you are not sure, estimate $ I SO K List ALL your assets and ALL your debts below. If you are not sure, estimate. Attach additional pages, if needed. Your Assets — If none, enter zero (0). Your Debts - How much do you owe now? Savings. stocks, bonds S (Z. • If none, enter zero (0). Real Property (house. Mortgage t • •Se•A Proceeds from life insurance S Loans S . 15 Is a private lawyer (not DA) representing you? 0 Yes 0 No If Yes' 6rcea, es)v-vcg vs Lawyers Name Address 16 Authorization to speak with representative: If you would like to give permission to a family member, Mend or other person to speak to OVS regarding your claim, enter here. Name of Person Address Phone 17 Victim/Claimant's Authorization: I ACKNOWLEDGE that accepbng an award from the Office of Victim Services (DVS) creates a ken in favor or the Stale of New York on any recovery retating to the aunt upon *Nth this claim is based. indudng any judgment. Settlement or order of resttuton I further authorize any funeral !erector. allerney. erne:Oyez police or ether pudic authority. insurance company a any person vino rendered services to the above, a hawig knowledge of the same, to furnish the OVS or ifs represematives the following nformallan Workers Ccrrgensaticn records. nfccmaeon relating to the cnme or any injunes or death suffered as the resiit of the acme, and information relating to this dam If an award is made. I aulhonze the OVS to make payments directly to the provider ist services I also authorize the OVS to share my intonation and records tempted For this claim wth the local Victim Assistance PrograrnIVAR) in order for the VAR to assist the OVS in processing my darn and making its delerminabon If a pnvale larger has been indicated above, I also authorize the OVS lo share my intormaton and records compiled for this dam wrh Vie lawyer in order for hather to act as my representative. I understand a separate NosceclAppearance from my lawyer Int be needed in addbon tres authonzation. If a randy member, bend or other ;world ovicated above. I authonze the OVS to share my nformation and records compled for this dam col shall bo deemed as effective as the 0- 1-- 1 -22...A '1A Date Email page you prefer to speak %English Q %nab 0 Simplified Chinese 4_, redeems; Chinese 0 Haman Cm* 0 Pea 0 Korean Interpreter Needed 0 Yes No 0 Russian 0 Omer To process your claim, mail us the following documents. (Keep a copy for your records.) • 14I bills and receipts for services listed on this form • Your completed, signed darn form • One completed HIPAA form for each service provider listed on this form (You can photocopy the HIPAA form ) • Letters from any insurers denying or authorizing payment tot the services listed on this form Remember You must tell your insurance company or benefits plan before the OVS can pay Mail your documents to: New York State Office of Victim Services AE Sine Building 80 S Swan Skeet Albany. NY 122108002 Rev September 2016 Page 4 014 EFTA01650842