Epstein Secrets

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cy Name) I0. Reason for release of information: At request of the individual for purports of establishing eligibility for New Fork State Office of Victim Services benefits. II. Date or event on which this authorization will expire: This authorization will apart upon the termination of the individual's eligi

on(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 Rev September 2015 Page 3 ol EFTA01650947 13 If the victim died, tell us about any life

NEW YORK STATE Office of Victim Services Claim Application and Instructions How to Apply for Compensation Who can apply for compensation? Innocent victims of crime, certain relatives, d

me of s covered by this insurance: Primary Insurance Company Major Medical Insurance Company Other Insurance (Union, Dental, Mims etc) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2015 Page 3 of 4 EFTA01651060 13 If the victim died, tell us about any lif

cy Name) 10. Reason for release of information: At request of the individual for purposes of establishing eligibility for New York State Office of Victim Services benefits. 12. If not the patient, name of person signing form: 11. Date or event on which this authorization will expire: This authorization will