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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
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
2 mentions1 same-page
Page ?Same page
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
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
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
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 New York State Law and the Social Security Death Benefit
Medicaid
ORGANIZATION4 w/ New·3 w/ the
HIPAA
ORGANIZATION4 w/ New·3 w/ the
First Hospital
ORGANIZATION3 w/ New·3 w/ the
Victim Services
ORGANIZATION3 w/ New·3 w/ the
CA
Complete Address
PERSON3 w/ New·3 w/ the
the New York State Department of Health'
ORGANIZATION3 w/ New·3 w/ the
the New York City Commission of Human Rights
ORGANIZATION3 w/ New·2 w/ the
See the Court Ordered Restitution Information
ORGANIZATION2 w/ New·2 w/ the
the State of New York
LOCATION2 w/ New·2 w/ the
The New York State Public Health Law
ORGANIZATION2 w/ New·2 w/ the
S. Swan
ORGANIZATION2 w/ New·2 w/ the
OVictim Assistance Program
ORGANIZATION2 w/ New·2 w/ the
Disability Insurance
ORGANIZATION2 w/ New·2 w/ the
the Death Certificate
ORGANIZATION2 w/ New·2 w/ the
Primary Insurance Company
ORGANIZATION2 w/ New·2 w/ the
Governmental Agency Name
ORGANIZATION2 w/ New·2 w/ the
Social Security Benefits
ORGANIZATION2 w/ New·2 w/ the