EFTA01650943.pdf

NEW YORK Office of Claim Application and STATE Victim Services Instructions How to Apply for Compensation Who can apply for compensation? Innocent victims of crime, certain relatives, dependents, What if I don't have some of the papers OVS legal guardians and eligible Good Samaritans can apply needs? to the Office of Victim Services (OVS) for compensation Send your application in right away. You can send the of out-of-pocket expenses not covered by insurance or other documents later. other resources. What if my property was lost, damaged or What kind of expenses can I get compensated destroyed because of the crime? for? If you are under 18, 60 or over, disabled or were injured, OVS offers compensation related to personal injury, you may apply for benefits to replace your essential death and loss of essential personal property. personal property or cash that was not covered by any The specific expenses OVS may cover include: other resource. • Medical, pharmacy and counseling expenses Essential means necessary for your health and welfare, • Loss of Essential Personal Property (up to $500, like eyeglasses and clothes. including $100 for cash) What if I move? • Burial or Funeral Expenses (up to $6.000) Send OVS a signed letter right away. Tell us your new • Lost Wages or Lost Support (up to $30.000) address and phone number. Also let us know if your (Parents or guardians of hospitalized minor children email address changes. may be eligible for this benefit) • Transportation (court/medical) Who can sign the claim? • Occupational/Vocational Rehabilitation Generally, the victim must sign the claim. However, if the • Security Devices and DV Shelter Costs victim is under 18, or is physically or mentally incapable • Crime scene clean-up (up to $2.500) of signing, then the legal guardian (the person receiving the benefits) must fill out section 2 of the claim and sign • Good Samaritan property losses (up to $5,000) the claim. • Moving expenses (up to $2.500) If the victim died, the person asking for benefits must fill out How do I ask for compensation? section 2 of the claim and sign the claim. Send us your completed OVS application along with Is there another way to apply? copies of: • Police reports Yes. Visit ovs.ny.gov to access the secure Victim Service • Medical bills Portal (VSP) and file an application on line. • Correspondence with insurance companies Do I have to fill out the attached HIPPA form? or benefits plan saying if they will cover your loss • Insurance cards Yes. Fill out one HIPAA form for each service provider. • Receipts for essential personal property You can photocopy a blank form to make extra copies. • Death certificate and funeral contract • Victim's birth certificate • Proof of age (driver's license, birth certificate etc.) • Legal guardianship papers 80 S. Swan Street 55 Hanson Place Albany, NY 12210-8002 Brooklyn, NY 11217-1523 (518) 457-8727 (718) 923-4325 ovs.ny.gov 800-247-8035 Rev. September 2015 EFTA01650943  Court Ordered Restitution Information What is restitution? Restitution is compensation paid to a victim by the perpetrator of a criminal offense for the losses or injuries incurred as a result of the criminal offense. It must be ordered by the Court at the time of sentencing, and is considered part of the sentence. Restitution is NOT for payment of damages for future losses, mental anguish or "pain and suffering." When the District Attorney's (DA) office advises the Court that you have requested restitution or when the victim impact statement contained in the probation investigation report (pre-sentence, pre-plea or pre-disposition report) indicates that the victim seeks restitution, the Court must order restitution unless the interests of justice dictate otherwise. When the judge does not order restitution, the judge must clearly state his/her reasons on the record. What can I request as restitution? You can ask for any expense you incur as a result of the criminal offense — even for items the OVS may not be able to reimburse. Restitution may include, but is not limited to, reimbursement for medical bills, counseling expenses, loss of earnings, funeral expenses, insurance deductibles and the replacement of stolen or damaged property. Who is entitled to restitution? Anyone who has been the victim of a criminal offense and has suffered injuries, economic losses or damages can seek restitution. Many times, victims who deserve restitution do not request it. This can occur because victims are not aware that they are entitled to restitution, or do not know what steps to take to go about receiving the restitution they deserve. How do I ask for restitution? You should contact the DA's office and advise them of the extent of your injury, your out-of-pocket losses and the amount of damages you are requesting. It is your responsibility to give the police, DA and, upon request, the local probation department copies of the bills and other documents showing the extent of your injuries, your out-of-pocket losses and the amount of damages you want considered by the Court. Your claim for restitution will be included in any probation investigation report (pre-sentence, pre-plea or pre-disposition report). Be sure to: • Keep accurate records such as original receipts of any expenses you have as a direct result of the criminal offense. • Give copies of these receipts to the police. DA and local probation department. You need to clearly explain your need for restitution as soon as possible to the DA, the victim/witness advocate, and the probation department. Plea agreements can occur within days of the actual criminal offense. If this information is not provided before the plea agreement and sentencing, you may have to pursue the perpetrator in Civil Court. The DA is under an obligation to petition the Court to order restitution on your behalf. In all felony criminal cases, many misdemeanor criminal cases and all juvenile delinquency and persons in need of supervision (PINS) cases, a pre-sentence or predisposition investigation report is required. The local probation department will contact you about the issue of restitution as it pertains to your case. How is restitution determined? The amount of restitution is based on proof of your out-of-pocket losses incurred as a result of the criminal offense. The perpetrator has a right to object to the amount of restitution. The Court may hold a hearing on the issue of restitution where the Court may consider the perpetrator's ability to pay. The DA's office may contact you and ask you to testify at the restitution hearing. If you have a concern about appearing personally in Court, you should explore alternatives with the DA assigned to your case. If the OVS has paid your bills, the Court may order that restitution payments be made to the OVS for those paid items. It is important that you advise the DA's Office that you filed a claim with the OVS. If you filed a claim with the OVS, it is important that you advise the OVS if the Court orders the perpetrator to pay restitution. Rev. September 2015 EFTA01650944  Read Application for Compensation How to Apply for New York State Office of Victim Services Compensation before filling out this form. Please print. Answer all questions. It is a crime to file a false claim! Victim Assistance Program Use Only Program Name,Phone Advocate Name/Email OvS VAP iDs 1 Tell us about the victim. MI Social Security sr Date of Birth Last Name First Name ck here if ou do not have one. Mailing .cress: State orForeign Counend illI M Street Apt. # (or Native OPaofic IslandenNabve Hawaiian [Other I:Muth-Race Race/EthnicityeWhite OBtadt DAsian OFIrsiaric 0 partner Marital Status: OSingle [Warned 20Svorced OSeparated [Widowed Olives** ['Unknown Gender: 0 Male .21eirmee Was the victim disabled at the time of the crime? 0Yes How did you first hear about the Office of Victim Services? OPolice 0Hosptai 0Disbnct Attorney OVictim Assistance Program ORadiofTV OBrochureiPoster I:Internet J26e, you. (See 'Who can sign the daim7 on the 2 If you are not the victim, and you are signing this claim, you are the claimant Tell us about instructions page.) First Name Ml Social Security N Date of Birth Last Name OCheck here if you do not have one. Mailing Address: City County Stele (or Foreign County) Zip Code Street Ape. U (or P.O. Box) What is your relationship to the victim? (Check only one.) (Explain' 0 Parent 0 Spouse 0 Child 0 Legal Guardian 0 Attorney 0 Other 3 Tell us about the crime. (Check only one ) The victim was injured because of The victim lost essential personal property The victim died because of 0 Aafl ❑ Stalking because of 0 Motcr vehicle (DUVIDWI) 0 Sexual Assad D Kidnapping 0 Mon 0 Burglary ❑ Motor Wilde (Omer) 0 Child Physical Abuse/Neglect ['Terrorism 0 Criminal D Motor Vehicle (OLNOWI) 0 Terrorism 0 Child Sexual Abuse 0 Ara Waif 0 Motor Vehicle (not DIRDWI) 0 Mott Vehicle (CLAW) 0 Robbery 0 Arson 0 Motor Vehicle (not OUVDM) 0 Human Trafficking O Human Traffiaing O Frauffinanoal 0 Human Traffidung 0 Robbery (No injury) Crime 0 Chad Pornography 0 Other fkrnode 0 Other (Explain) 0 Other (Exp/ain) 0 Apt. Bldg. 0 Public Street Where did the crime happen? (Check only one.) 0 Work 0 Owned residence 0Subway/Bus 0Parking Lot 0Restaurant/Bar DSchoarSch oot grounds 0Shopping Mall 0 Other (Explain): O Yes O No O Unknown Was this a crime related to domestic violence? O Yes O No O Unknown Was this a crime related to bullying? Was this a crime related to elder abuse/neglect? ❑ Yes ❑ No O Unknown Was this a hate crime? O Yes O No ❑ Unknown Was the victim driving a livery cab when the crime happened? O Yes O No El Unknown Was the victim's property lost or damaged while trying to prevent or stop a crime against someone else or while helping the authorities stop the crime? ❑ Yes 0 No Crime Report 0: Police or criminal justice agency reported to: County where crime happened: Date of crime: Date crime was reported: If more than 7 days between the date of crime and date the crime was reported, explain why: why: If more than 1 year between the date of crime and the date you are filing this claim, explain Describe the crime in your own words: Rev. September 2015 EFTA01650945  know): 1 . _ar Alidlin Tell us abo ut the susp ect. Suspects name (if you 4 arrested for this crime Oyes 0 No Has the suspect ❑ Yes 0 No 0 Not Yet d for this crim e/ Has the suspect been prosecute e as the victim Does the suspect live in the same hous 's family? 0 yes 0 No ber of the victim OR is the suspect a mem attach a copy.) ction in this case 0 yes 0 No Of Yes. , Has the court issued an order of prote 0 Not Yet restitution? 0 yes 0 No Has the DA asked the courtto order )0 No OHM Yet restitution? 0 Yes (Amount S Did the court order the suspect to pay items should also be expenses listed below. These le for comp ensa tion, the OVS may be able to reimburse for the n with pros ecuto rs if there is a criminal NOTE - If you are eligib icant s are enco urag ed to share this informatio ution . Appl requested as part of court ordered restit information about restitution. n Information page for important case. See the Court Ordered Restitutio y.) to this crime. (Check all that appt 5 Tell us about your expenses related 0 Lost Wag es Personal Transportation O medicaukroutance 0 Loss of Suppon 0 MedicS ounseling (Dea th Claim Only ) 0 DV Shelter O Came Scene Cleanup 0 Moving/Storage 0 Court rity e/Sys tem 0 Voca riona vReh abilitation O Secu Devic Essential Personal Property 0 Funeral/Bona! 0 O Counseling O Other (Explain): . _ be replaced because of prop erty , like cash , eyeg lass es, or clothing that needs to 6 List any essential personal this crime. (If none. skip to 7) Cost Cost Describe what was lost/damaged. Describe what was lost/d ama ged: $ $ 3. 1. $ $ 4. 2. 5 $ 6. 3. Deductible Policy or ID it Homeowner/Renter insurance Company Deductible Policy or ID s $ AutqCrther Insurance Company 15. — onal property benefits, skip to were no inju ries and you are only asking for essential pers — If there rance for Lost Wages. parent's employment and insu Tell us about the victim's or the ed for Lost Wages. (Skip to 8.) 7 t us to con tact you r emp loye r, you cannot ask to be reimburs If you do not wan ? 0 Yes 0 No (If No. skip to 8.) victim /pare nt of hosp italiz ed mino r victim employed when the crime happened Was the the crime? 0 Yes 0 No minor victim miss work because of Did the victim/parent of hospitalized s of last year 's federal tax return and all schedules.) /pare nt self-emp loyed ? 0 Yes 0 No (If Yes, attach copie Was the victim Phone It Employees Name. Address, and t Zip code Phone X Street City Employer and Phone*. Other Employers Name. Address. ) Sete °P c** Pha se Street coy Employer go to work: doctor who certified victim could not Name, Address, and Phone/Sof ) _ t stree city Zip Code Phon e # Stem Doctor none, mite 'None" below and skip to 8.) ance com pany that will cover the victim's lost time at work. (If Tell us about any insur Policy or ID I or -None Policy or ID/tor 'None 5. Workers' Compens ation 1. Unemployment Insurance 6. Other insurance 2. Disability Insurance SSN 7. Social Security Benefits (ssn 3. Pension Plan requi red) SSN 8. SSI Benefits (ssn required) 4. Othe r insur ance not, skip to 9.) have any burial expenses. (If If the victim died, till out below it you Death Certificate, if you have them. of Me funer al hom e contr act, othe r bills for burial expenses, and a photocopy of the Also. attach a copy Phone L ___1 -- Name dFoetalHome: Address: Siart. Z p Code Street Page 2 cr I Cs.rommirsadr EFTA01650946  se of this crime, fill out below. 9 If the victim was injured or died becau Describe the victim's injuries. briefly. section10.) ent? ❑ Yes ❑ No (If No, skip to Did the victim receive any medical treatm to this crime: treated the victim for injuries related Tell us about the health professionals who Phone Full Name Complete Address First Hospital Other Hospital First Doctor (not in hospital) Other Doctor First Dentist Victim's Counselor rt. (If none. skip to 1 1. who depended on the victim for suppo 10 Tell us about the victim's dependents or others Relationship to Victim Social Security 4 Date of Bob Name Dependent Are you the legal Address guardian? ❑ Yes ❑ No Date of Birth Relationship to Victim Name Social Security # Other Dependent Are you the legal Address guardian? ❑ Yes ❑ No Date of Birth Relationship to Victim Name Social Security a Other _ -_ • _ Dependent Are you the legal Address guardian? ❑ Yes ❑ No and check here: ❑ If more than 3 dependents. attach a separate sheet eling because of this crime? (If no. skip to 12.) 11 Did anyone besides the victim receive couns Insurance company billed for counseling Policy or ID # Who received counseling? Relationship to Victim Counselors name, address and phone*: Insurance company billed for counseling Policy or ID k Who else received counseling? Relationship to Victim Counselor's name. address and phone ft. e of this crime. check here and attach a separate sheet to describe. ❑ If more than 2 people received counseling becaus the victim's dependents. If no insurance, write "None" below. 12 List any insurance covering the victim or write "Pending" under Policy or ID #. If you have applied but are not covered yet. Policy or ID # Name of person(s) covered by Ibis insurance. Primary Insurance Company Major Medical Insurance Company Other Insurance (Union. Dental. Vision. etc.) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Page 3 ol Rev September 2015 EFTA01650947  its. 13 If the victim died, tell us about any life Insurance and death benef death benefits, skip to 14.) (I! the victim did not die. or does not have any life insurance or Address Phone lY Policy or ID # Company Name Life Insurance Pension Plan I Other insurance/Plan Medicaid ) Workers' Compensation If any other insurance or death benefits. list here: Do any of these policies cover the victim's burial expenses? O Yes O No Has anyone applied for the Social Security Death Benefit? O Yes O No below.), none. enter zero Wt. 14 Tell us about your financial situation. You MUST fill out ALL sections How many dependents do you have? $ What is your total annual income (from ALL sources)? If you are not sure, estimate: sure, estima te. Attach additional pages, if needed. List ALL your assets and AU. your debts below. If you are not Your Assets — If none enter zero (0). _ Your Debts - How much do you owe now? H none, enter zero (0). Savings, stocks. bonds Real P (house etc. $ Mortgage Loans $ I Proceeds from life insurance $ 15 Is a private lawyer (not DA) representing you? O Vas O No If Yes: O OVS Claim O Chit Suit O Both ) Address Phone Lawyers Name 16 Authorization to speak with representative: If you would like to give permission to a family member, friend or other person to speak to OVS regarding your claim, enter here. L Address Phone is Name of Person 17 Victim/Claimant's Authorization: any recovery relating to Sented (OVS) creates a hen m favor of the State of New York on I ACKNOWLEDGE that accepting an award from the Office of Victim e any funeral Breda. attorney. employer. t settlement or order of restitution. I further authoriz the crime upon which this dam is based. inducting any Judgmen to above. or having knotaed ge of the same, to furnish the OVS or its who rendered services the pace or other pubic authority nascence company or any person a death suffered as the result of the records, information relating to the came or any injuries representatives the following information- Workers Otimpensatial ts drectly to the provider of swim . I also authoriz e the made, I authonze the OVS to make paymen cane, and information relating to this dam If an award is for the VAP to assist the OVS in dean with the local Victim Assistance Program (VA?) in order OVS to share my inkarnabon and records caroled for this also authoriz e the OVS to share my informab on and records lawyer has been indicated above. I proosssng my darn and making its determination If a private nce from my lawyer will be the lawyer in order for hirniticr to act as my representative. I understand a separate Notice of Appeara prow fa this darn with . Mend a other person is indicated above. I authoriz e the OVS to share my information and records needed in adCtOn to this authonzaton If a family member dam dam wrth that person in order that they assist me with this authorization f tive as the ' • Date Daytime Phone I Simplified Chinese = you prefer to speak: alecon 0 Spanish O Email O Haitian Creole O baleen O Korean al Chinese O No O Russian O Other Interpreter Needed O Yes s.) following documents. (Keep a copy for your record To process your claim, mail us the • All bills and receipts for sennces listed on this form • Your completed, signed claim form form ) provider listed on this form (You can photocopy the HIPAA • One completed HIPAA farm for each service this form. ing payment fa the services listed on • Letters from any insurers denying or authoriz benefits plan before the OVS can pay. Remember You must bill your insurance company or State Office of Victim Services Mail your documents to: New York AE Smith Bulking 80 S. Swan Street Abany, NY 12210-8002 Pegs 4 of 4 ti Sweater 2015 EFTA01650948  OCA (Mimi Form \o.: 960 ak: • H 1 AA• 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 Birth Social Security Number XXX-XX-_ Patient Address or my authorized representative. request that health information regarding my care and treatment be released as set forth on this form. In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 IIIIPAA 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. It' I am authorizing the release of HIV-related, alcohol 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 HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information. I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human 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 care 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 N'ITHANPONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9(b). 7 Name and address of health provider or entity to release this information: 8 Name and address of person(s) or category of 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 O Medical Record from (insert date) to (insert date) O Entire 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. Include: (indicate by Initialing) Akohol/Drug 'Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) O By initialing here I authorize Initials Name of 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 (Attorney/Firm Name or Governmental Agency Name) 10 Reason for release of information. I I Date or event on which this authorization will expire At request elite individualforpurposes ofestablishing This authorization will expire upon the termination of the eligibilityfor New York Stair Office of Victim Services individual's eligibilityfor Office of Victim Services benefits benefit 12 If not the patient, name of person signing form 13 Authority to sign on behalf of patient All ite my questions about this form have been answered. In addition, I have been provided a copy of the Date: by law • Human mmun e macs was a causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as has log HIV symptoms or infection and information regarding a person's contacts. EFTA01650949