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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
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
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
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
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
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
Entities connected to both Complete Address and the New York State Department of Health'

Medicaid
ORGANIZATIONVictim Services
ORGANIZATIONHIPAA
ORGANIZATIONNew York State Law
ORGANIZATIONFirst Hospital
ORGANIZATIONthe Social Security Death Benefit
ORGANIZATIONPrimary Insurance Company
ORGANIZATIONSee the Court Ordered Restitution Information
ORGANIZATIONGovernmental Agency Name
ORGANIZATIONThe New York State Public Health Law
ORGANIZATIONS. Swan
ORGANIZATIONOVictim Assistance Program
ORGANIZATIONDisability Insurance
ORGANIZATIONthe State of New York
LOCATIONthe New York City Commission of Human Rights
ORGANIZATIONthe Death Certificate
ORGANIZATIONSocial Security Benefits
ORGANIZATION