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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
FTA01650840 •HIPAA• OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health' Patient Name Date of Binh I or my authorized representative, request that health information regarding my cart and treatment be released asset for
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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
1650948 OCA (Mimi Form \o.: 960 ak: • H 1 AA• AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA 'This form has been approved by the New York State Department of Health' Patient Name Date of Birth Social Security Number XXX-XX-_ Patient Address or my authorized representative. request that health information reg
2 mentions1 same-page
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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
Ot:A Official Form No.: 960 H1PAA• AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health' I, or my authorized representative, request that h h information regarding my care and treatment be released as set forth on this form: In accorda
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Mutual Connections (17)
Entities connected to both Victim Services and the New York State Department of Health'
Medicaid
ORGANIZATION3 w/ Victim·3 w/ the
HIPAA
ORGANIZATION3 w/ Victim·3 w/ the
CA
Complete Address
PERSON3 w/ Victim·3 w/ the
New York State Law
ORGANIZATION3 w/ Victim·3 w/ the
First Hospital
ORGANIZATION3 w/ Victim·3 w/ the
the Social Security Death Benefit
ORGANIZATION3 w/ Victim·3 w/ the
Primary Insurance Company
ORGANIZATION2 w/ Victim·2 w/ the
See the Court Ordered Restitution Information
ORGANIZATION2 w/ Victim·2 w/ the
Governmental Agency Name
ORGANIZATION2 w/ Victim·2 w/ the
The New York State Public Health Law
ORGANIZATION2 w/ Victim·2 w/ the
S. Swan
ORGANIZATION2 w/ Victim·2 w/ the
OVictim Assistance Program
ORGANIZATION2 w/ Victim·2 w/ the
the State of New York
LOCATION2 w/ Victim·2 w/ the
the New York City Commission of Human Rights
ORGANIZATION2 w/ Victim·2 w/ the
Disability Insurance
ORGANIZATION2 w/ Victim·2 w/ the
Social Security Benefits
ORGANIZATION2 w/ Victim·2 w/ the
the Death Certificate
ORGANIZATION2 w/ Victim·2 w/ the