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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
nsation If any other insurance or death benefits. list here. Do any of these policies cover the victim's burial expenses? Has anyone applied for the Social Security Death Benefit? K yes 0 Yes 0 No 0 No 14 Tell us about your financial situation. You MUST fill out ALL sections below. If none, enter zero (0). How many depe
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
If any other insurance or death benefits. list here: Do any of these policies cover the victim's burial expenses? O Yes O No Has anyone applied for the Social Security Death Benefit? O Yes O No 14 Tell us about your financial situation. You MUST fill out ALL sections below.), none. enter zero Wt. How many dependents do you ha
2 mentions1 same-page
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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
f any other insurance or death benefits, list here: Do any of these policies cover the victim's burial expenses? 0 Yes 0 No Has anyone applied for the Social Security Death Benefit? 0 Yes K No 14 Tell us about your financial situation. You MUST fill out j, sections below. If none, enter zero (01. How many dependents du you
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Mutual Connections (17)
Entities connected to both Medicaid and the Social Security Death Benefit
HIPAA
ORGANIZATION9 w/ Medicaid·3 w/ the
New York State Law
ORGANIZATION4 w/ Medicaid·3 w/ the
Victim Services
ORGANIZATION3 w/ Medicaid·3 w/ the
CA
Complete Address
PERSON3 w/ Medicaid·3 w/ the
First Hospital
ORGANIZATION3 w/ Medicaid·3 w/ the
the New York State Department of Health'
ORGANIZATION3 w/ Medicaid·3 w/ the
the New York City Commission of Human Rights
ORGANIZATION3 w/ Medicaid·2 w/ the
Social Security Benefits
ORGANIZATION3 w/ Medicaid·2 w/ the
Disability Insurance
ORGANIZATION3 w/ Medicaid·2 w/ the
The New York State Public Health Law
ORGANIZATION2 w/ Medicaid·2 w/ the
S. Swan
ORGANIZATION2 w/ Medicaid·2 w/ the
OVictim Assistance Program
ORGANIZATION2 w/ Medicaid·2 w/ the
the Death Certificate
ORGANIZATION2 w/ Medicaid·2 w/ the
the State of New York
LOCATION2 w/ Medicaid·2 w/ the
Primary Insurance Company
ORGANIZATION2 w/ Medicaid·2 w/ the
See the Court Ordered Restitution Information
ORGANIZATION2 w/ Medicaid·2 w/ the
Governmental Agency Name
ORGANIZATION2 w/ Medicaid·2 w/ the