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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
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
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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
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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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
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 Victim Services and the Social Security Death Benefit
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 New York State Department of Health'
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