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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
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
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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
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
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
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 Victim Services and First Hospital
Medicaid
ORGANIZATION3 w/ Victim·3 w/ First
HIPAA
ORGANIZATION3 w/ Victim·3 w/ First
CA
Complete Address
PERSON3 w/ Victim·3 w/ First
New York State Law
ORGANIZATION3 w/ Victim·3 w/ First
the New York State Department of Health'
ORGANIZATION3 w/ Victim·3 w/ First
the Social Security Death Benefit
ORGANIZATION3 w/ Victim·3 w/ First
Primary Insurance Company
ORGANIZATION2 w/ Victim·2 w/ First
See the Court Ordered Restitution Information
ORGANIZATION2 w/ Victim·2 w/ First
Governmental Agency Name
ORGANIZATION2 w/ Victim·2 w/ First
The New York State Public Health Law
ORGANIZATION2 w/ Victim·2 w/ First
S. Swan
ORGANIZATION2 w/ Victim·2 w/ First
OVictim Assistance Program
ORGANIZATION2 w/ Victim·2 w/ First
the State of New York
LOCATION2 w/ Victim·2 w/ First
the New York City Commission of Human Rights
ORGANIZATION2 w/ Victim·2 w/ First
Disability Insurance
ORGANIZATION2 w/ Victim·2 w/ First
Social Security Benefits
ORGANIZATION2 w/ Victim·2 w/ First
the Death Certificate
ORGANIZATION2 w/ Victim·2 w/ First