Epstein Secrets

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

tim 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 sectfon10.)77t* ge-c- A0V-n+ VI S EACri to this crime: Phone X 10 Tell us about the victim's dependents or o depended on the

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

Yes K No (If No, skip to 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 victi

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

O Yes O No (If No, 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 u