Ovs Application Form – Fill Out and Use This PDF

New York State

Office of Victim Services

Claim Application and Instructions

Rev. December 2013

Victim Assistance Program Use Only

1Tell us about the victim.

How did you first hear about the Office of Victim Services?

2If you are not the victim, and you are signing this claim, you are the claimant. Tell us about you. (See “Who can sign

the claim?” on the instructions page.)

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 crime 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: ____________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________

4 Tell us about the suspect. Suspect’s name (if you know):

NOTE - If you are eligible for compensation, the OVS may be able to reimburse for the expenses listed below. These items should also be requested as part of court ordered restitution. Applicants are encouraged to share this information with prosecutors if there is a criminal case. See the Court Ordered Restitution Information page for important information about restitution.

5Tell us about your expenses related to this crime. (Check all that apply.)

6List any essential personal property, like cash, eyeglasses, or clothing that needs to be replaced

because of this crime. (If none, skip to 7.)

1._________________________________________________ $ ______________________ 4. _________________________________________________ $ __________________________

2._________________________________________________ $ ______________________ 5. _________________________________________________ $ __________________________

— If there were no injuries and you are only asking for essential personal property benefits, skip to 15. —

7Tell us about the victim’s or the parent’s employment and insurance for Lost Wages.

If you do not want us to contact your employer, you cannot ask to be reimbursed for Lost Wages. (Skip to 8.)

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.)

8If 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.

9If the victim was injured or died because of this crime, fill out below.

Describe the victim’s injuries, briefly:

_________________________________________________________________________________________________________________________

10Tell us about the victim’s dependents or others who depended on the victim for support. (If none, skip to 11.)

If more than 3 dependents, attach a separate sheet and check here:

11 Did anyone besides the victim receive counseling because of this crime? (If no, skip to 12.)

Counselor’s name, address and phone #:

Counselor’s name, address and phone #:

If more than 2 people received counseling because of this crime, check here and attach a separate sheet to describe.

12List 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 #.

Primary Insurance Company

Major Medical Insurance Company

Other Insurance (Union, Dental, Vision, etc.)

Medicare

Medicaid

Workers’ Compensation

Auto Insurance

Other insurance

13If 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.)

14Tell us about your financial situation. You MUST fill out ALL sections below. If none, enter zero (0).

How many dependents do 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.

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.

17Victim/Claimant’s Authorization:

I ACKNOWLEDGE that accepting an award from the Office of Victim Services (OVS) creates a lien 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 OVS 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 OVS to make payments directly to the provider of services. I also authorize the OVS 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 OVS in processing my claim and making its determination. If a private lawyer has been indicated above, I also authorize the OVS to share my information and records compiled for this claim with the lawyer in order for him/her 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 OVS to share my information and records compiled for this claim with that person in order that they assist me with this claim.

A photocopy of this authorization shall be deemed as effective as the original.

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 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.

New York State Office of Victim Services AE Smith Building

80 S. Swan Street Albany, NY 12210-8002

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 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 (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 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 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 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 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:

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.

(b)  By initialing here ____________ I authorize ________________________________________________________________

All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.

*Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person’s contacts.