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-c- LLD gess, 1/4.,e_ Pigs 3 of 4 EFTA01650840 •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 tha
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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s. (Keep a copy for your records.) • All bills and receipts for sennces listed on this form • Your completed, signed claim form • One completed HIPAA farm for each service provider listed on this form (You can photocopy the HIPAA form ) • Letters from any insurers denying or authorizing payment f
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
Page ?Same page
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 regardin
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 HIPAA and the Social Security Death Benefit
Medicaid
ORGANIZATION9 w/ HIPAA·3 w/ the
New York State Law
ORGANIZATION4 w/ HIPAA·3 w/ the
First Hospital
ORGANIZATION3 w/ HIPAA·3 w/ the
Victim Services
ORGANIZATION3 w/ HIPAA·3 w/ the
CA
Complete Address
PERSON3 w/ HIPAA·3 w/ the
the New York State Department of Health'
ORGANIZATION3 w/ HIPAA·3 w/ the
the New York City Commission of Human Rights
ORGANIZATION3 w/ HIPAA·2 w/ the
See the Court Ordered Restitution Information
ORGANIZATION2 w/ HIPAA·2 w/ the
the State of New York
LOCATION2 w/ HIPAA·2 w/ the
The New York State Public Health Law
ORGANIZATION2 w/ HIPAA·2 w/ the
S. Swan
ORGANIZATION2 w/ HIPAA·2 w/ the
OVictim Assistance Program
ORGANIZATION2 w/ HIPAA·2 w/ the
Disability Insurance
ORGANIZATION2 w/ HIPAA·2 w/ the
the Death Certificate
ORGANIZATION2 w/ HIPAA·2 w/ the
Primary Insurance Company
ORGANIZATION2 w/ HIPAA·2 w/ the
Social Security Benefits
ORGANIZATION2 w/ HIPAA·2 w/ the
Governmental Agency Name
ORGANIZATION2 w/ HIPAA·2 w/ the