Epstein Secrets

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

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

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

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

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

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