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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
Page 3 of 4 EFTA01650819 •RIPAA' OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIP In accordance with New York State Law and the Privacy Rule of the I lealth Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may inc
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ofarson's, myerefl by this incritiner Pnmary Insurance Company Major Medical Insurance Company Other Insurance (Union, Deed& Vision at) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2016 I . ._ct-c- LLD gess, 1/4.,e_ Pigs 3 of 4 EFTA01650840 •HIPAA• OC
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 inclu
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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
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
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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
y authorized representative, request that h h 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 (HIPAA), I understand that: 1. This authorization may inclu
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Mutual Connections (22)
Entities connected to both Medicaid and New York State Law
Albany
LOCATION11 w/ Medicaid·2 w/ New
HIPAA
ORGANIZATION9 w/ Medicaid·4 w/ New
New York State
LOCATION8 w/ Medicaid·3 w/ New
Richard Kahn
PERSON7 w/ Medicaid·2 w/ New
the New York City Commission of Human Rights
ORGANIZATION3 w/ Medicaid·3 w/ New
the New York State Department of Health'
ORGANIZATION3 w/ Medicaid·3 w/ New
the Social Security Death Benefit
ORGANIZATION3 w/ Medicaid·3 w/ New
Victim Services
ORGANIZATION3 w/ Medicaid·3 w/ New
First Hospital
ORGANIZATION3 w/ Medicaid·3 w/ New
CA
Complete Address
PERSON3 w/ Medicaid·3 w/ New
Social Security Benefits
ORGANIZATION3 w/ Medicaid·2 w/ New
Disability Insurance
ORGANIZATION3 w/ Medicaid·2 w/ New
The New York State Public Health Law
ORGANIZATION2 w/ Medicaid·2 w/ New
NEW YORK NY
LOCATION2 w/ Medicaid·2 w/ New
the State of New York
LOCATION2 w/ Medicaid·2 w/ New
the New York State Division of Human Rights
ORGANIZATION2 w/ Medicaid·2 w/ New
See the Court Ordered Restitution Information
ORGANIZATION2 w/ Medicaid·2 w/ New
S. Swan
ORGANIZATION2 w/ Medicaid·2 w/ New
OVictim Assistance Program
ORGANIZATION2 w/ Medicaid·2 w/ New
the Death Certificate
ORGANIZATION2 w/ Medicaid·2 w/ New