Epstein Secrets

tim 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 sectfon10.)77t* ge-c- A0V-n+ VI S EACri to this crime: Phone X 10 Tell us about the victim's dependents or o depended on the

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

Yes K No (If No, skip to 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 victi

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

O Yes O No (If No, 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 u

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