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victim receive any medical treatment? 0 Yes J (If No, skip to Tell us about the health professionals who treated the victim 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 sect
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
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o 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 victim's dependents or other
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
2 mentions1 same-page
Page ?Same page
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 us about the vict
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
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Entities connected to both First Hospital and the New York State Department of Health'
CA
Complete Address
PERSON3 w/ First·3 w/ the
New York State Law
ORGANIZATION3 w/ First·3 w/ the
HIPAA
ORGANIZATION3 w/ First·3 w/ the
the Social Security Death Benefit
ORGANIZATION3 w/ First·3 w/ the
Victim Services
ORGANIZATION3 w/ First·3 w/ the
Medicaid
ORGANIZATION3 w/ First·3 w/ the
OVictim Assistance Program
ORGANIZATION2 w/ First·2 w/ the
Disability Insurance
ORGANIZATION2 w/ First·2 w/ the
the Death Certificate
ORGANIZATION2 w/ First·2 w/ the
Primary Insurance Company
ORGANIZATION2 w/ First·2 w/ the
Governmental Agency Name
ORGANIZATION2 w/ First·2 w/ the
The New York State Public Health Law
ORGANIZATION2 w/ First·2 w/ the
the State of New York
LOCATION2 w/ First·2 w/ the
the New York City Commission of Human Rights
ORGANIZATION2 w/ First·2 w/ the
Social Security Benefits
ORGANIZATION2 w/ First·2 w/ the
See the Court Ordered Restitution Information
ORGANIZATION2 w/ First·2 w/ the
S. Swan
ORGANIZATION2 w/ First·2 w/ the