EFTA01651057.pdf

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 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 include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV• RELATED INFORMATION only if I 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 My in Item 0(a), I specifically authorize release of such information to the percnn(c) indicated in Item 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 WV-related information without authorization. If I experience discrimination because of the release or disclosure of WV-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 care 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. 5. Information disclosed under this authorization might be redisclosed 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). 7. Name and address ofhealth provider or entity to release this information: 8. Name and address of person(s) or category of person to whom this information will be sent: NYS OFFICE OF VICTIM SERVICES - AE SMITH BLDG., 80 S. SWAN ST., ALBANY, NY 12210-8002 9(a). Specific information to be released: ❑ Medical Record from (insert date) to (insert date) ❑ Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. ❑ Other: Include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information IIIV-Related Information (b) O By initialing here I authorize Initials Name of individual health care provider to discuss my health information with my attorney. or a governmental agency, listed here: NEW YORK STATE OFFICE OF VICTIM SERVICES (Attomey/Fimi Name or Governmental Agency Name) 10. Reason for release of information: 11. Date or event on which this authorization will expire: At request of the individualfor purposes of establishing This authorization will expire upon the termination of the eligibilityfor New York State Office of Victim Services individual's eligibility for Office of Victim Services benefits. benefits. 12. If not the patient, name of person signing form: 13. Authority to sign on behalf of patient: has about this form have iition, I have been provided a co Date: The New York State Public Health Law protects information which rcasonanry count mentity someone as nas mg MIT symptoms or infection and information regarding a person's contacts. EFTA01651057  Read Application for Compensation How to Apply for New York State Office of Victim Services Compensation before filling out this form. Please print. Answer ail questions. /t is a crime to file a false claim! r ictim Assistance Program Use Only OVS VAR ott ram Name/Flume Advocate Name/Email 1 I Tell us about the victim. I net Mama First Name MI Social Security Si Date of Birth Raise/Ethnlogy:OWhite OBlack OAWan OHisPanic OArnerican IndiaC/Alaskan Native [Pacific Islander/Native Hawaiian 00ther0Aulti-Race Marital Status: OSingle 54Manied ODivorced OSeparated [Widowed °Lives with partner Gender: O Male ter Female I Was the victim disabled at the time of the crime? OYes 11No ['Unknown How did you first hear about the Office of Victim Services? ['Police OHosprtal ODistnot Attorney OVictim Assistance Program OfiadioliV akochurePoster ['Internet xelOther 2 If you are not the victim, and you are signing this claim, you are the claimant. Tell us about you. (See 'Who can skin the claim? on the instructions page.) Last Name First Name Mt Social Security it Date of Birth °Check here if you do not have one. - I Mailing Address: I Street Apt. # (orP.O. Box) City County State (orForeign Cooney) Zip Code What is your relationship to the victim? (Check only one.) O Parent O Spouse O Child O Legal Guardian O Attorney O Other (Explain): ._. 3 Tell us about the crime. (Check only one.) The victim died because of: The victim was injured because of: The victim lost essential personal property ID Motor Vehicle (DUI/DWI) ❑ Assault O Stalking because of. O Sexual Assault O Kidnapping ❑ Motor Vehicle (Other) El Burglary El Arson O Child Physical Abuse/Neglect O Terrorism O Terrorism O Motor Vehicle (DUI/DWI) O Criminal O Child Sexual Abuse O Arson O Arson ❑ Motor Vehicle (DUIrDWI) El Robbery ❑ Motor Vehicle (not DUI/DWI) Mischief ❑ Human Trafficking O Motor Vehicle (not DUI/DWI) O Human Trafficking 0 Human Trafficking ❑ Fraud/Financid. O Other I {mikado O Child Pornography El Robbery (No injury) Crime El Other (Explain): O Other (Explain): Where did the crime happen? (Chock only ono.) O Work O Owned residence O Apt. Bldg. O Public Street OSubway/Bus OParking Lot ORestaurant/Bar OSchool/Se,hool grounds OShopping Mall O Other (Explain): Was this a crime related to domestic violence? 0 Yes 0 No 0 Unknown Was this a crime related to bullying? 0 Yes 0 No 0 Unknown Was this a crime related to elder abuse/neglect? 0 Yes 0 No 0 Unknown Was this a hate crime? 0 Yes 0 No 0 Unknown Was the victim driving a livery cab when the crime happened? 0 Yes 0 No O Unknown Was the victim's property lost or damaged while trying to prevent or stop a crime against someone else or while helping the authorities stop the crime? .. O Yes ❑ No Crime Report #: Police or criminal justice agency reported to: County where crime happened: Date of crime: Date crime was reported: If more than 7 days between the date of orime and date the crime was reported, explain why: If more than 1 year between the date of crime and the date you are filing this claim, explain why: Describe the crime in your own words: Iev September 2015 EFTA01651058  4 Toll us a bout the suspect. Suspect's name (if you know): this the suspect been arrested for this crime? -1 -an a viedim O Yes O No g a Has the suspect been prosecuted for this crime? O Yes O No O Not Yet Does the suspect live in the same house as the victim OR is the suspect a member of the victim's family? O Yes O No Has the court issued an order of protection in this case? O Yes O No (I/ Yes, attach a copy) Has the DA asked the court to order restitution? O Yes O No O Not Yet Did the court order the suspect to pay restitution? O Yes (Amount S ) O No O Not Yet NOTE - If you are eligible for compensation. the OVS may be able to reimburse for the expenses listed below requested as part of court ordered restitution. Applicants These items should also be are encouraged to share this information with prosecutors if case. See the Court Ordered Restitution there is a criminal Information page for important information about restitution. 6 Tell us about your expenses related to this crime. (Check all that apply) O MedicaVAmbulance 0 Loss of Support O Lost Wages Personal Transportation O Crime Scene Cleanup CI Security uevece/system (Death Claim Only) U VocationsiMenabilitation O DV Shelter O Moving/Storage fl medical!eminseii,x, O Court O Counseling O FuneraVBurial O Essential Personal Property O Other (Explain): 6 List any essential personal prope rty, like cash, eyeglasses, or clothing that needs to be replac this crime. (If none, skip to 7.) ed because-or Describe what was lost/damaged: Cost Describe what was lost/damaged: Cost 1. 5 3. $ 2. $ 4. $ 3. 6. $ Homeowner/Renter Insurance Company I Pokey or ID* Deductible Auto/Other Insurance Company Polity or ID # Deductible $ — if there were no injuries and you are only asking for essential personal property benef its, skip to 16. — 7 Tell us about the victim's or the parent's employment and insurance for Lost Wages. If you do not want us to contact your emplo yer, you cannot ask to be reimbursed for Lost Wages. (Skip to 8.) Was the victim/parent of hospitalized minor victim employed when the crime happened? ri Yes ❑ Nn (If No, skip to S.) Da the victim/parent of hospitalized minor victim miss work because of the crime? 0 Yes 0 No Was the victim/parent self-employed? 0 Yes 0 No (If Yes, attach copies of last year's federa l tax return and all schedules.) Employers Name, Address, and Phone #: Employer Street Ctql State Zip Code Phone a Other Employer's Name, Address, and Phone #: Employer Street City State Zip Code Phone # Name, Address, and Phone # of doctor who certified victim could not go to work: Doctor Street City ( ) Slate Zip Code Phone # Tell us about any insurance company that will cover the victim's lost time at work. (If none, write 'None' below and skip to 8.) Policy or lOtor *None 1. Unemployment Insurance Policy or ID # or 'None 5. Workers' Compensation 2. Disability Insurance 6. Other insurance 3. Pension Plan 7. Social Security Benefits (ssn SSN required) 4. Other insurance 8. SSI Benefits (ssn required) SSN 8 If the victim died, fill out below if you have any burial expenses. (If not, skip to 9.) Also. attach a copy of the funeral home contract, other bills for burial expenses, and a photocopy of the Death Certificate, if you have them. Name of Funeral Home Phone ft Address State Zip Code Rev. September 2015 Page 2 of EFTA01651059  9 If the victim was injured or died because of this crime, fill out below. Describe the victim's injuries, briefly: Did the victim receive any medical treatment? 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 Phone It 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 others who depended on the victim for support. (Ifnone, skip to 11.) Name Social Security # Date of Birth Relationship to Victim Dependent - - ' Address Are you the legal guardian? O Yes O No Name Social Security # Date of Birth Relationship to Victim Other Dependent Address Are you the legal guardian? O Yes O No Other Name Social Security # Date of Birth Relationship to Victim Dependent - - Address Are you the legal guardian? O Yes O No 171010 than 3 dependents, attach a separate sheet and check here: 0 11 Did anyone besides the victim receive counseling because of this crime? (If no, skip to 12.) I Who received counseling? Relationship to Victim I Insurance company billed for counseling Policy or ID # i Counselor's name, address and phone #: Who else received counseling? Counselors name, address and phone it Relationship to Victim I Insurance company billed for counseling Policy or ID # If more than 2 people received counseling because of this crime, check here and attach a separate sheet to describe. ID 12 List any insurance covering the victim or the victim's dependents. if no insurance, write "None" below. If you have applied but are not covered yet, write "Pending" under Policy or ID #. Policy or ID # Name of s covered by this insurance: Primary Insurance Company Major Medical Insurance Company Other Insurance (Union, Dental, Mims etc) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2015 Page 3 of 4 EFTA01651060  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 IS Policy or ID # Life Insurance ( ) Pension Plan Other ( ) Insurance/Plan f ) Medicaid I 1 Workers' Compensation If 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 ❑ 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 have? What is your total annual income (from ALL sources)? If you are not sure, estimate: $ List ALL your assets and ALL your debts below. If you are not sure, estimate. Attach additional pages, if needed. Your Assets — If none, enter zero (0). Your Debts — How much do you owe now? Savings, stocks, bonds $ If none, enter zero (0). Real Property (house, etc.) $ Mortgage $ Proceeds from life insurance $ Loans $ 16 s a private lawyer (not DA) representing you? 0 Yes ❑ No If Yes: 0 OVS Claim 0 Civil Suit 0 Both ( Lawyer's Name Address Phone # 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. Name of Person Address Phone it 17 Victim/Claimant's Authorization: I ACKNOWLEDGE that auxpting an award from me Mee or victim services (OVS) aeates a hen in favor of the State of New York on any recovery relating to the crime upon which this claim is based, including any judgment, settlement or order of restitution. I further authorize any funeral director, attorney, employer, police or other public authority, insurance company or any person who rendered services to the above, or having knowledge of the same, to furnish the 0VS or its representatives the following information: Workers' Compensation records, information relating to the crime or any injuries or death suffered as the result of the crime, and information relating to this claim. If an award is made, I authorize the 0VS to make payments directly to the provider of services. I also authorize the 0VS to share my information and records compiled for this claim with the local Victim Assistance Program (VAP) in order for the VAP to assist the 0VS in processing my claim and making its determination. If a private lawyer has been indicated above, I also authorize the 0VS to share my information and records compiled for this claim with the lawyer in order for haulier to act as my representative. I understand a separate Notice of Appearance from my lawyer will be needed in addition to this authorization. If a family member, friend or other person is indicated above, I authorize the 0VS to share my information and records compiled for this claimAvith that person in order that they assist me with this claim. lion shall be doomed at affattivsb fts_tim_rie Language you prefer to speak: p., DI English 0 Spanish 0 Simplified Chinese 0 Traditional Chinese 0 Haitian Creole 0 Italian 0 Korean Interpreter Needed: 0 Yes No 0 Russian 0 Other To process your claim, mail us the following documents. (Keep a copy for your records.) • M bills and receipts for services listed on this form • Your completed, signed claim form • One completed HIPAA form 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 plan before the OVS can pay. Mail your documents to: New York State Office of Victim Services AE Smith Building 80 S. Swan Street Albany, NY 12210-8002 Rev September 2015 Page 4 of 4 EFTA01651061