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EFTA00018845 | EFTA00018851 OCA Official Form No.: 960 4,11,111111 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 Patient Address I. or my 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 IIIPAA). I understand that I 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 box in Item 9(a). I specifically authorize release of such information to the person(s) indicated in Item 8 2. It' 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 HIV-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 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 redisclosurc 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 TILE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b). 7 Name and address of health 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' to (insert date) O Medical Record from (insen date) O 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. Include: (Indicate by Initialing) O Other Alcohol/Drug Treatment Mental Health Information HIV-Related Information Authorization to Discuss Health Information I authorize (b) O By initialing here Name ofindividual health care provider Initials to discuss my health information with my attorney, or a governmental agency, listed here. NEW YORK STATE OFFICE OF VICTIM SERVICES (Attorney/Firm Name or Governmental Agency Name) 10 Reason for release of information. At request ofthe Mdividualforpurposes ofestablishing eligibiliryfor New York State Office of Victim Services benefits 12 If not the patient, name of person signing form II Date or event on which this authorization will expire This authorization will expire upon the termination of the individual's eligibilityfor Office of Victim Services benefit 13 Authority to sign on behalf of patient All of Si • a reasonably could identify someone as having symptoms or infection and information regarding a person's contacts. EFTA00018851
February 12, 2026 at 7:59 PM
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EFTA00018845 | EFTA00018850 death benefits. 13 If the victim died, tell us about any life Insurance and or death benefits, skip to 14.) nce life insura any have (If the victim did not die. or does not Phone a Address Company Name I Life Insurance Medicaid Workers Compensation 14 ) ) Pension Plan Other Insurance/Plan 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? Policy or ID O Yes O No O Yes O No I ) I ) I ) . none. enter zero (01. Tell us about your financial situation. You MUST fill out ha sections below if How many dependents do you have? sure, estimate: What is your total annual income (from ALL sources)? If you are not te. Mach additional pages, if needed. estima sure, List ALL your assets and ALL your debts below. If you are not Your Debts - How much do you owe now? Your Assets — If nom enter zero (0). If none, enter zero (0). $ Savings. stodts. bonds $ Mortgage Real Property (house, etc,) $ Loans Proceeds from life insurance S i 15 is a private lawyer (not DA) representing you? O Yes °No If Yes: O OVS Claim O Civil Suit O Both 16 ) Phone N Address Name s Lawyer Authorization to speak with representative: claim, enter here. r, friend or other person to speak to OVS regarding your If you would like to give permission to a family membe I_-1. Phone e Address Name of Person 17 Victim/Claimant's Authorization: on any recovery relating to of Vicbm Services (OVS) creates a lien in favor of the Stated New York !ACKNOWLEDGE that accepting an award from the Office diredor, attorney. employer. funeral e any any judgment. Settlement or order of restitution. I further authoriz the OVS or its furnish the an upon which this dam is based. including to same, the of ge knoafed having Or who rendered sernces to the above. result of the the Folios or other public aufhady, esuranas company or any person as suffered records, information relabng to the crime or any injuneS a death the auttonze representatives the following information. Waters Compensation also I . micas of provider the to erectly s made. I authorize the OVS to make pervert on, and information relating to this dam If an award is VAP to assist the OVS in the for order in (VAP) Program ce Assistan Victim local the hx this claim with DVS to share my ofcaruzbon and records compiled share my information ard records a private lawyer has been indicated above. I also authorize the OVS to processing my claim and making its deteminabon If of Appearance from my lawyer will be to act as my representative. I understand a separate Notice for compiled fOr this Clan wit the lawyer in order himiliec to share my information ard records OVS the ze . !nand a other parson is indicated above. 'authori needed in Waco to this authonzabon If a family member dam aim with that person in order that they assist me with this eep a following documents. To process your claim, mail us the All biils and receipts fa services listed on this form • Your completed. signed claim form • HIPAA form ) provider listed on this km (You can photocopy the One completed HIPAA tom) for each service • form. payment for the services listed on this Letters from any insurers denying or authorizing • y or benefits plan before the 0VS can pay. Remember You must bill your insurance compan s New York State Office of Victim Service Mail your documents to: AE Smith Buiking 80 S. Swan Street Abany, NY 12210-8002 Page 4 of 4 r Sapwnber 2015 EFTA00018850
February 12, 2026 at 7:59 PM
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EFTA00018845 | EFTA00018849 9 se of this crime, fill out below. If the victim was injured or died becau Describe the victim's injuries. briefly. section10.) ent? ❑ Yes ❑ No (If No, skip to Did the victim receive any medical treatm to this crime: treated the victim for injuries related Tell us about the health professionals who Complete Address Full Name 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 others Name Dependent Address Other Dependent Other Dependent rt. (If none. skip to 1 1. Relationship to Victim who depended on the victim for suppo Date of Bob Social Security 4 Social Security # Name Date of Birth Are you the legal guardian? ❑ Yes ❑ No Relationship to Victim Date of Birth Are you the legal guardian? ❑ Yes ❑ No Relationship to Victim Address Name _ Social Security a _ • -_ Address If more than 3 dependents. attach a separate sheet Are you the legal guardian? ❑ Yes ❑ No and check here: ❑ eling because of this crime? (If no. skip to 12.) 11 Did anyone besides the victim receive couns Insurance company billed for counseling Relationship to Victim Who received counseling? Policy or ID # Counselors name, address and phone*: Who else received counseling? Relationship to Victim Insurance company billed for counseling Policy or ID k Counselor's name. address and phone ft. e of this crime. check here and attach a separate sheet to describe. ❑ If more than 2 people received counseling becaus 12 the victim's dependents. If no insurance, write "None" below. List any insurance covering the victim or write "Pending" under Policy or ID #. If you have applied but are not covered yet. Name of person(s) covered by Ibis insurance. Policy or ID # Primary Insurance Company Major Medical Insurance Company Other Insurance (Union. Dental. Vision. etc.) Medicare Medicaid Workers' Compensation Auto Insurance Other insurance Rev September 2015 Page 3 ol EFTA00018849
February 12, 2026 at 7:59 PM
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EFTA00018845 | EFTA00018848 T 4 Has the suspect been arres ❑Nc4 Yet O yes ❑No d for this crime? Was the suspect been prosecute the same house as the victim Does the suspect live in ID yes O No the victim's family? OR is the suspect a member of Of Yes. attach a copy.) ? protection in this case CLI yes El NO Has the court issued an order of Yet 0 yes 0 NO 0 Not r restitution? Has the DA asked the court to orde )ON° ❑ Not Yet Yes (Amount S ? ution restit pay to ect susp the r orde t Did the cour s should also be nses listed below. These item able to reimburse for the expe be is a criminal may there OVS if the rs tion, ecuto ensa pros comp for with n le NOTE - If you are eligib share this informatio to ed urag enco are s icant Appl . ution ution. requested as pan of court ordered restit important information about restit t Ordered Restitution Information page for case. See the Cour y.) to this crime. (Check all that appt Personal Transportation Tell us about your expenses related 5 es Wag Lost 0 0 Loss of Suppon 0 Medical/Counseling 0 MedicauArntiulance 0 DV Shelter ) Only Claim th (Dea 0 Carrie Scene Cleanup 0 Court 0 Moving/Storage VRehabilitation bona Voca 0 tem e/Sys Devic rity 0 Secu 0 Essential Personal Property 0 Funeral/Buns! 0 Counseling _ . CI Other (Explain): be replaced because of or clothing that needs to es, lass eyeg , , cash like erty prop List any essential personal 6 Cos; this crime. (If none. skip to 7.) Describe what was lost/damaged. Cost Describe what was lost/damaged: 1. 2. 3. $ 3. $ 4. $ 6. $ S Deductible Policy or ID it HomeowneriRenter insurance Company Deductrbre Policy or ID * Auterither Insurance Company 7 $ $ erty benefits, skip to 15. — asking for essential personal prop only are you and ries inju no were — If there e for Lost Wages. parent's employment and insuranc for Lost Wages. (Skip to 8.) Tell us about the victim's or the you cannot ask to be reimbursed r, loye emp r you tact con to us t If you do not wan 0 Yes O No (If No. skip to 8.) victim employed when the crime happened? r mino ed italiz hosp of nt /pare victim Was the O Yes O No the aim.? ed minor victim miss work because of Did the victim/parent of hospitaliz 's federal tax return and all schedules.) year last of s O No (If Yes, attach copie Yes O ? loyed emp selfnt /pare victim Was the e II: I Employees Name. Address, and Phon t Phone X t Col Zip City Street Employer Other Employers Name. Address. and Street Employer Phone*. City ( State °Pc** ) Phone 0 certified victim could not go to work: ) Name, Address, and Phone/Sof doctor who ( city # e Phon code _ street _ ZIP Stare Doctor (If none, write *None- below and skip to 8.) . wank at cover the victim's lost time will that pany com ance insur Tell us about any Policy or ID I or 'None Policy or ID/tor 'None I. Unemployment Insurance 2. Disability Insurance 3. Pension Plan 4. Other insurance 5. Workers' Compensation 6. Other insurance 7. Social Security Benefits (ssn SSN required) 8. SSI Benefits (ssn required) SSN skip to 9.) have any burial expenses. (If not, If the victim died, till out below it you of the Death Certificate, it you have them. copy fox burial expenses, and a photo Digs r othe act, contr e al hom funer the h of attac a copy Also. Phone L ___1 -_ Name Foetal Home: Address: Street Siab. Zp Code Page 2 ol I Cs.rommihase EFTA00018848
February 12, 2026 at 7:59 PM
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EFTA00018845 | EFTA00018847 Read How to Apply for Compensation before filling out this form. Application for Compensation New York State Office of Victim Services Please print. Answer all questions. It is a crime to file a false claim! Victim Assistance Program Use Only Advocate Name/Email Ragmen Name/Phone OVS VAP iDe the victim. 2 if you are not the victim, and you are signing this claim, you are the claimant Tell us about instructions page.) First Name Last Name MI you. (See -Who can sign the daim7 on the Social Security a Date of Birth Seto (orForel9n County) Zip Code Dated( here if you do not have one. Mailing Address: Street City Apt. it (or P.O. Box) County What is your relationship to the victim? (Check only one.) Other (Explain! 0 Parent 0 Spouse 0 Child 0 Legal Guardian 0 Attorney 0 3 Tell us about the crime. (Check only one.) The victim was injured because of. The victim died because of 0 Assault 0 swam ❑ Mob Vehicle (DUVDWI) ❑ Motor Vehicle (Other) Terrorism 0 Pam 0 KerlaPP02 Sexual Assault 0 0 Child Physical Abuseleglect 0 Terror sal 0 Child Soul Abuse 0 Arson 0 haw wade (outowi) ❑ Robbery The victim lost essential personal property because of 0 Arson 0 BUrtilry 0 Mob vehicle (DUI/DWI) 0 criminal 0 Motor Vehicle (nor DUI/DWI) Mschief 0 Mato( Vehicle (rat DUOS/ 0 Human Trafficking 0 RHumobt: 0 Hunan Tracing (No 0 ChM PollblaPhY _ 0 Oaten Hcenicide 0 Other (Explain): 0 Other (EsSibif0: Apt. Bldg. 0 Public Street Where did the crime happen? (Check only one.) 0 Work 0 Owned residence 0 °Subway/Bus 0Parlung Lot ORestauranVBar °School/School grounds °Shopping Mall 0 Other (Explain): Was this a crime related to domestic violence? Was this a crime related to bullying? Was this a crime related to elder abuse/neglect? Was this a hate crime? Was the victim driving a livery cab when the crime happened? a Was the victim's property lost or damaged while trying to prevent or stop the stop crime? authorities the crime against someone else or while helping Crime Report 0: FraudiFinancial Crime 0 Yes 0 No ❑ Unknown 0 Yes 0 No 0 Unknown 0 Yes 0 No 0 Unknown 0 Yes 0 Yes 0 No El Unknown I:j Unknown 0 Yes 0 No 0 No Police or criminal justice agency reported to: Date crime was reported: Date of crime: County where crime happened: explain why: If more than 7 days between the date of crime and date the crime was reported, 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: Rev, September 2015 EFTA00018847
February 12, 2026 at 7:58 PM
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EFTA00018845 | EFTA00018846 Court Ordered Restitution Information What is restitution? Restitution is compensation paid to a victim by the perpetrator of a criminal offense for the losses or injuries incurred as a result of the criminal offense. It must be ordered by the Court at the time of sentencing, and is considered part of the sentence. Restitution is NOT for payment of damages for future losses, mental anguish or "pain and suffering." When the District Attorney's (DA) office advises the Court that you have requested restitution or when the victim impact statement contained in the probation investigation report (pre-sentence, pre-plea or pre-disposition report) indicates that the victim seeks restitution, the Court must order restitution unless the interests of justice dictate otherwise. When the judge does not order restitution, the judge must clearly state his/her reasons on the record. What can I request as restitution? You can ask for any expense you incur as a result of the criminal offense — even for items the OVS may not be able to reimburse. Restitution may include, but is not limited to, reimbursement for medical bills, counseling expenses, loss of earnings, funeral expenses, insurance deductibles and the replacement of stolen or damaged property. Who is entitled to restitution? Anyone who has been the victim of a criminal offense and has suffered injuries, economic losses or damages can seek restitution. Many times, victims who deserve restitution do not request it. This can occur because victims are not aware that they are entitled to restitution, or do not know what steps to take to go about receiving the restitution they deserve. How do I ask for restitution? You should contact the DA's office and advise them of the extent of your injury, your out-of-pocket losses and the amount of damages you are requesting. It is your responsibility to give the police, DA and, upon request, the local probation department copies of the bills and other documents showing the extent of your injuries, your out-of-pocket losses and the amount of damages you want considered by the Court. Your claim for restitution will be included in any probation investigation report (pre-sentence, pre-plea or pre-disposition report). Be sure to: • Keep accurate records such as original receipts of any expenses you have as a direct result of the criminal offense. • Give copies of these receipts to the police. DA and local probation department. You need to clearly explain your need for restitution as soon as possible to the DA, the victim/witness advocate, and the probation department. Plea agreements can occur within days of the actual criminal offense. If this information is not provided before the plea agreement and sentencing, you may have to pursue the perpetrator in Civil Court. The DA is under an obligation to petition the Court to order restitution on your behalf. In all felony criminal cases, many misdemeanor criminal cases and all juvenile delinquency and persons in need of supervision (PINS) cases, a pre-sentence or predisposition investigation report is required. The local probation department will contact you about the issue of restitution as it pertains to your case. How is restitution determined? The amount of restitution is based on proof of your out-of-pocket losses incurred as a result of the criminal offense. The perpetrator has a right to object to the amount of restitution. The Court may hold a hearing on the issue of restitution where the Court may consider the perpetrator's ability to pay. The DA's office may contact you and ask you to testify at the restitution hearing. If you have a concern about appearing personally in Court, you should explore alternatives with the DA assigned to your case. If the OVS has paid your bills, the Court may order that restitution payments be made to the OVS for those paid items. It is important that you advise the DA's Office that you filed a claim with the OVS. If you filed a claim with the OVS, it is important that you advise the OVS if the Court orders the perpetrator to pay restitution. Rev. September 2015 EFTA00018846
February 12, 2026 at 7:58 PM
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EFTA00018845 | EFTA00018845 er rNEW YORK STATE Office of Victim Services Claim Application and Instructions How to Apply for Compensation Who can apply for compensation? Innocent victims of crime, certain relatives, dependents, legal guardians and eligible Good Samaritans can apply to the Office of Victim Services (OVS) for compensation of out-of-pocket expenses not covered by insurance or other resources. What if I don't have some of the papers OVS needs? Send your application in right away. You can send the other documents later. What kind of expenses can I get compensated for? OVS offers compensation related to personal injury, death and loss of essential personal property. What if my property was lost, damaged or destroyed because of the crime? If you are under 18, 60 or over, disabled or were injured, you may apply for benefits to replace your essential personal property or cash that was not covered by any other resource. The specific expenses OVS may cover include: • Medical, pharmacy and counseling expenses • Loss of Essential Personal Property (up to $500, including $100 for cash) • Burial or Funeral Expenses (up to $6.000) • Lost Wages or Lost Support (up to $30.000) (Parents or guardians of hospitalized minor children may be eligible for this benefit) • Transportation (court/medical) • Occupational/Vocational Rehabilitation • Security Devices and DV Shelter Costs • Crime scene clean-up (up to $2.500) • Good Samaritan property losses (up to $5,000) • Moving expenses (up to $2,500) How do I ask for compensation? Send us your completed OVS application along with copies of: • Police reports • Medical bills • Correspondence with insurance companies or benefits plan saying if they will cover your loss • Insurance cards • Receipts for essential personal property • Death certificate and funeral contract • Victim's birth certificate • Proof of age (driver's license, birth certificate etc.) • Legal guardianship papers 80 S. Swan Street Albany, NY 12210-8002 (518) 457-8727 ovs.ny.gov Essential means necessary for your health and welfare, like eyeglasses and clothes. What if I move? Send OVS a signed letter right away. Tell us your new address and phone number. Also let us know if your email address changes. Who can sign the claim? Generally, the victim must sign the claim. However, if the victim is under 18, or is physically or mentally incapable of signing, then the legal guardian (the person receiving the benefits) must fill out section 2 of the claim and sign the claim. If the victim died, the person asking for benefits must fill out section 2 of the claim and sign the claim. Is there another way to apply? Yes. Visit ovs.ny.gov to access the secure Victim Service Portal (VSP) and file an application on line. Do I have to fill out the attached HIPPA form? Yes. Fill out one HIPAA form for each service provider. You can photocopy a blank form to make extra copies. 55 Hanson Place Brooklyn, NY 11217-1523 (718) 923-4325 800-247-8035 Rev. September 2015 EFTA00018845
February 12, 2026 at 7:58 PM