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e company or benefits Van before the OVS can pay Mall your documents to: New York Slate Office of Wien Services AE Smith &Acing 80 S Swan Street Albany. NY 122108002 Rnv September 2016 Page 4 04 EFTA01650821
ion 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
2 mentions1 same-page
Page ?Same page
tached HIPPA form? Yes. Fill out one HIPAA form for each service provider. You can photocopy a blank form to make extra copies. 80 S. Swan Street Albany, NY 12210-8002 (518) 457-8727 ovs.ny.gov 55 Hanson Place Brooklyn, NY 11217-1523 (718) 923-4325 800-247-8035 Rev. September 2015 EFTA01650943
tion 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
2 mentions
Page EFTA00018845
tached HIPPA form? Yes. Fill out one HIPAA form for each service provider. You can photocopy a blank form to make extra copies. 80 S. Swan Street Albany, NY 12210-8002 (518) 457-8727 ovs.ny.gov 55 Hanson Place Brooklyn, NY 11217-1523 (718) 923-4325 800-247-8035 Rev. September 2015 EFTA00018845
Page: EFTA00018845 →Page EFTA00018851
tion 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 t
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2 mentions
Page EFTA00038436
tached HIPPA form? Yes. Fill out one HIPAA form for each service provider. You can photocopy a blank form to make extra copies. 80 S. Swan Street Albany, NY 12210-8002 (518) 457-8727 ovs.ny.gov 55 Hanson Place Brooklyn, NY 11217-1523 (718) 9234325 800-247-8035 Rev. September 2015 EFTA00038436
Page: EFTA00038436 →Page EFTA00038442
tion 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 arc responsible for protecting my rights. 3. 1 have the right to revoke this authorization at any time by writing
Page: EFTA00038442 →Sponsored
Mutual Connections (10)
Entities connected to both Albany and the New York City Commission of Human Rights
New York State
LOCATION37 w/ Albany·2 w/ the
the State of New York
LOCATION33 w/ Albany·3 w/ the
Victim Services
ORGANIZATION28 w/ Albany·2 w/ the
Medicaid
ORGANIZATION11 w/ Albany·3 w/ the
New York State Law
ORGANIZATION2 w/ Albany·3 w/ the
HIPAA
ORGANIZATION2 w/ Albany·3 w/ the
AE SMITH BLDG.
ORGANIZATION2 w/ Albany·2 w/ the
STATE Office of
ORGANIZATION2 w/ Albany·2 w/ the
Major Medical Insurance Company
ORGANIZATION2 w/ Albany·2 w/ the
the New York State Division of Human
ORGANIZATION2 w/ Albany·2 w/ the