Back to Network
3
Shared Docs
3
Same-Page
3 / 3
Mentions
Document Mentions (3 shared documents)
2 mentions1 same-page
Page ?Same page
have any life insurance or death benefits skip to 14 ) Company Name Address Phone I Life Insurance _ Pension Plan — Other InsuranceiPlan — Medicaid Workers Compensation If any other insurance or death benefits. list here: Do any of these policies Cover the =Ws burial expenses' Has anyone app
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
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
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 mentions1 same-page
Page ?Same page
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
ation because of the release or disclosure of WV-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
Sponsored
Mutual Connections (19)
Entities connected to both Medicaid and the New York City Commission of Human Rights
Albany
LOCATION11 w/ Medicaid·4 w/ the
HIPAA
ORGANIZATION9 w/ Medicaid·3 w/ the
New York State
LOCATION8 w/ Medicaid·2 w/ the
New York State Law
ORGANIZATION4 w/ Medicaid·3 w/ the
CA
Complete Address
PERSON3 w/ Medicaid·2 w/ the
First Hospital
ORGANIZATION3 w/ Medicaid·2 w/ the
Victim Services
ORGANIZATION3 w/ Medicaid·2 w/ the
the State of New York
LOCATION2 w/ Medicaid·3 w/ the
Social Security Benefits
ORGANIZATION3 w/ Medicaid·2 w/ the
the New York State Department of Health'
ORGANIZATION3 w/ Medicaid·2 w/ the
the Social Security Death Benefit
ORGANIZATION3 w/ Medicaid·2 w/ the
Disability Insurance
ORGANIZATION3 w/ Medicaid·2 w/ the
S. Swan
ORGANIZATION2 w/ Medicaid·2 w/ the
OVictim Assistance Program
ORGANIZATION2 w/ Medicaid·2 w/ the
The New York State Public Health Law
ORGANIZATION2 w/ Medicaid·2 w/ the
the Death Certificate
ORGANIZATION2 w/ Medicaid·2 w/ the
See the Court Ordered Restitution Information
ORGANIZATION2 w/ Medicaid·2 w/ the
Primary Insurance Company
ORGANIZATION2 w/ Medicaid·2 w/ the
Governmental Agency Name
ORGANIZATION2 w/ Medicaid·2 w/ the