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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
victim receive any medical treatment? 0 Yes J (If No, skip to Tell us about the health professionals who treated the victim for injuries related First Hospital Other Hospital First Doctor (riot on hospta0 Other Doctor First Dentist Victim s Counselor Full Name Complete Address rnfvtc f.-r(1-‘c sect
2 mentions1 same-page
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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
o section10.) Tell us about the health professionals who treated the victim for injuries related to this crime: Full Name Complete Address Phone First Hospital Other Hospital First Doctor (not in hospital) Other Doctor First Dentist Victim's Counselor 10 Tell us about the victim's dependents or other
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
skip to sectIon10.) Tell us about the health professionals who treated the victim for Injuries related to this crime: Full Name Complete Address First Hospital Other Hospital First Doctor (not in hospital) Other Doctor First Dentist Victim's Counselor Phone It ) ( ) ) 10 Tell us about the vict
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Mutual Connections (17)
Entities connected to both Medicaid and First Hospital
HIPAA
ORGANIZATION9 w/ Medicaid·3 w/ First
New York State Law
ORGANIZATION4 w/ Medicaid·3 w/ First
Victim Services
ORGANIZATION3 w/ Medicaid·3 w/ First
CA
Complete Address
PERSON3 w/ Medicaid·3 w/ First
the New York State Department of Health'
ORGANIZATION3 w/ Medicaid·3 w/ First
the Social Security Death Benefit
ORGANIZATION3 w/ Medicaid·3 w/ First
the New York City Commission of Human Rights
ORGANIZATION3 w/ Medicaid·2 w/ First
Social Security Benefits
ORGANIZATION3 w/ Medicaid·2 w/ First
Disability Insurance
ORGANIZATION3 w/ Medicaid·2 w/ First
The New York State Public Health Law
ORGANIZATION2 w/ Medicaid·2 w/ First
S. Swan
ORGANIZATION2 w/ Medicaid·2 w/ First
OVictim Assistance Program
ORGANIZATION2 w/ Medicaid·2 w/ First
the Death Certificate
ORGANIZATION2 w/ Medicaid·2 w/ First
the State of New York
LOCATION2 w/ Medicaid·2 w/ First
Primary Insurance Company
ORGANIZATION2 w/ Medicaid·2 w/ First
See the Court Ordered Restitution Information
ORGANIZATION2 w/ Medicaid·2 w/ First
Governmental Agency Name
ORGANIZATION2 w/ Medicaid·2 w/ First