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

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

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

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

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

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