EFTA01650819

9 If the victim was injured or died because of this crime, fill out below. 10 Tell us about the victim's dependents or others who depended on the victim for support. al none, skip toil) If more than 3 dependents, attach a separate sheet and check hem 11 Did anyone besides the victim receive counseling because of this crime? (If no. skip to 12) Who received counseling, Relationship to Victim Insurance company billed for counseling Counselors name. address and phone # Who else received counseling? Policy or I0 Relationship to Victim Insurance company billed for counseling Policy or ID # Counselors name, address and phone # If more than 2 people received counseling because of this clime. check here and attach a separate sheet to describe K 12 List any insurance covering the victim or the victim's dependents. If no insurance, write "None" below If u have applied but are not covered yet, write "Pending" under Policy or ID IS. Rev September 2016 Page 3 of 4 EFTA01650819 •RIPAA' OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIP In accordance with New York State Law and the Privacy Rule of the I lealth Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes. and CONFIDENTIAL HIV* RELATED INFORMATION only ill place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information. and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8 2. If I am authorizing the release of HIV-related. alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my IIIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information. I may contact the New York State Division of Human Rights at (212) 480- 2493 or the New York City Commission of Human Rights at (212) 306.7450. These agencies are responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the health can provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. S. Information disclosed under this authorization might be redisclmed by the recipient (except as noted above in Item 2). and this redisclosure may no longer be protected by federal or state law. 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). ,,,,, l•-••••••••y r•••••••••••• ••• • ... • • `" • *a. owe... rcasonably could identify someone as having IIIV symptoms or infection anil inlormalion regarding a person's contacts. EFTA01650820 13 If the victim died, tell us about any life Insurance and death benefits. (If the victim did not die. or does not have any life insurance or death benefits skip to 14 ) Company Name Address Phone I Life Insurance _ Pension Plan — Other InsuranceiPlan — Medicaid Workers Compensation If any other insurance or death benefits. list here: Do any of these policies Cover the =Ws burial expenses' Has anyone applied for the Social Security Death Benefit') O yes O Yes O NO ONG Policy or ID # 14 Tell us about your financial situation. YOU MUST fill out ALL sections below. If none, enter zero (01. 15 Is a private lawyer (not DA) representing you? O Yes O No 16 Authorization to speak with representative: If you would like to give permission to a family member, friend or other person to speak to OVS regarding your claim. enter here. 1 Name of Person Address Phone 17 VictimICIalmant's Authorization: I ACKNOWLEDGE that accepong an award from the °fined Warn Services (OVS) creates a fen in fare( of theStae of New York on any recovery relating to the onme upon *hell this claim is based. indudng any joie:mini. settlement or order of resttulon I further authorize any tuned director. anomey, ennplOyer, poke or other public authority. insurance company or any person who rendered services to the above, a having IcnoiMedge of the sane. to furnish the OVS or 45 representatives the fodo.ving nformaton Workers Corrbensation records. aformatscn relating to the mole or any injuries or death suffered as the restit of the owe and information relating to this dam If an award is made. I authorize the OVS to make payments directly to the provider of sensces. I also authorize the OVS to share my information and records complied for the claim *Ahernlocal Victim Assistance Program (VAP) in order for the VAP to assist the OVS in processing my clam and making its derdminabon renovate lawyer has been inkcaled above I also authorize the 0VS to share my informal= and records compiled for this clam with the lawyer in order for WANT to ad as my representative. I understand a separate Noce of Appearance from my lawyer rne be needed n addhat togas asehonzation. If a Ian* member, bend or other person is imitated abase, I authcnre the OVS to share my information and records compiled for this dam To process your claim, mail us the following documents. (Keep a copy for your records.) • All bills and receipts for services listed on this form • Your completed. signed darn form • One completed HIPAA Porn for each service provider listed on this form (You can photocopy the HIPAA form ) • Letters from any insurers denying or authorizing payment for the services listed on this form Remember You must bill your insurance company or benefits Van before the OVS can pay Mall your documents to: New York Slate Office of Wien Services AE Smith &Acing 80 S Swan Street Albany. NY 122108002 Rnv September 2016 Page 4 04 EFTA01650821