EFTA00038436

2 _ , A4EW YORK Office of Claim Application and STATE Victim Services Instructions How to Apply for Compensation Who can apply for compensation? Innocent victims of crime, certain relatives, dependents, What if I don't have some of the papers OVS legal guardians and eligible Good Samaritans can apply needs? to the Office of Victim Services (OVS) for compensation Send your application in right away. You can send the of out-of-pocket expenses not covered by insurance or other documents later. other resources. What if my property was lost, damaged or What kind of expenses can I get compensated destroyed because of the crime? for? If you are under 18, 60 or over, disabled or were injured, OVS offers compensation related to personal injury, you may apply for benefits to replace your essential death and loss of essential personal property. personal property or cash that was not covered by any The specific expenses OVS may cover include: other resource. • Medical, pharmacy and counseling expenses Essential means necessary for your health and welfare, • Loss of Essential Personal Property (up to $500, like eyeglasses and clothes. including $100 for cash) What If I move? • Burial or Funeral Expenses (up to $6,000) Send OVS a signed letter right away. Tell us your new • Lost Wages or Lost Support (up to $30,000) address and phone number. Also let us know if your (Parents or guardians of hospitalized minor children email address changes. may be eligible for this benefit.) • Transportation (court/medical) Who can sign the claim? • Occupational/Vocational Rehabilitation Generally, the victim must sign the claim. However, if the • Security Devices and DV Shelter Costs victim is under 18, or is physically or mentally incapable • Crime scene clean-up (up to $2,500) of signing, then the legal guardian (the person receiving the benefits) must fill out section 2 of the claim and sign • Good Samaritan property losses (up to $5,000) the claim. • Moving expenses (up to $2,500) If the victim died, the person asking for benefits must fill out How do I ask for compensation? section 2 of the claim and sign the claim. Send us your completed OVS application along with Is there another way to apply? copies of: • Police reports Yes. Visit ovs.ny.gov to access the secure Victim Service • Medical bills Portal (VSP) and file an application on line. • Correspondence with insurance companies Do I have to fill out the attached HIPPA form? or benefits plan saying if they will cover your loss • Insurance cards Yes. Fill out one HIPAA form for each service provider. • Receipts for essential personal property You can photocopy a blank form to make extra copies. • 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 55 Hanson Place Albany, NY 12210-8002 Brooklyn, NY 11217-1523 (518) 457-8727 (718) 9234325 ovs.ny.gov 800-247-8035 Rev. September 2015 EFTA00038436 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 EFTA00038437 Read Application for Compensation How to Apply for New York State Office of Victim Services Compensation before filling out this form. Please print. Answer all questions. It is a crime to file a false claim! Victim Assistance Program Use Only OVS VAP IDe Program Name/Phone Advocate Name/Email 1 Tell us about the victim. Race/EthnIcIty:OVVhite OBladi ['Asian OHispanic OAmencan Indian/Alaskan Native OPacific Islander/Native Hawaiian 00TherarAulti-Race Marital Status: OSingle .2fiAarned ODivorced OSeparated ['Widowed Olives with partner Gender: O Male Zfemale Was the victim disabled at the time of the crime? OYes J2tglo I:Unknown How did you first hear about the Office of Victim Services? OPoice OHospital ODistrict Attorney OVictim Assistance Program ORadio/TV OBrochure/Poster OIntemet dither 2 If you are not the victim, and you are signing this claim, you are the claimant. Tell us about you. (See ' ho can sign the daimr on the instructions page.) Last Name First Name MI Social Security # Date of Birth DCheck hem d you do not have one. Mailing Address: Street Apt. # (or P.O. Sox) City County State (or Foreign Country) 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 o Motor Vehicle (DUVDWI) O AsSauk O Stalking because of: O Motor Vehicle (Other) O Sexual Assault O Kidnapping O Burglary O Arson O Child Physical Abuse/Neglect O Terrorism Motor Vehicle (DUUDWI) O Criminal O Terrorism O Child Sexual Abuse O Mon O O Arson O Motor Vehicle (not OUPDHIS Mischief O Mote Vehicle (DUUDWI) O Robbery O Human Trafficking O Motor Vehide (not DtlYDWO O Human Trafficking 0 Human Trafficking ❑ Fraud/Fmandal O Chad Pornography O Robbery (No injury) Crime O Other Homicide: O Other (Explain): O Other (Explain): Where did the crime happen? (Check only one.) O Work O Owned residence O Apt. Bldg. O Public Street OSubway/Bus OParldng Lot ORestaurant/Bar OSchool/School grounds OShopping Mall O Other (Explain): Was this a crime related to domestic violence? 0 Yes CI No El Unknown Was this a crime related to bullying9 CI Yes 0 No 0 Unknown Was this a crime related to elder abuse/neglect? El Yes 0 No ID Unknown Was this a hate crime? 0 Yes ❑ No El Unknown Was the victim driving a livery cab when the crime happened? 0 Yes 0 No 0 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 O 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 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: Rev. September 2015 EFTA00038438 4 Tell us about the suspect. Suspect's name (if you know): Has the suspect been arrested for this crime? Has the suspect been prosecuted for this crime? i ga/72 a.. ViceLS ❑ Yes El No ❑ Yes 0 No 0 Not Yet ca°6-4-47 Does the suspect live in the same house as the victim OR is the suspect a member of the victim's family? ❑ Yes ❑ No Has the court issued an order of protection in this case? 0 Yes 0 No (If Yes, attach a copy.) Has the DA asked the court to order restitution? 0 Yes 0 No 0 Not Yet Did the court order the suspect to pay restitution? 0 Yes (Amount $ )0 No 0 Not Yet 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. 5 Tell us about your expenses related to this crime. (Check all that apply.) E Medical/Ambulance 0 Loss of Support 0 Lost Wages Personal Transportation 0 Crime Scene Cleanup (Death Claim Only) 0 DV Shelter 0 Medical/Counseling 0 Security Device/System ❑ Vocational/Rehabilitation 0 Moving/Storage El Court 0 Counseling 0 Funerateurial 0 Essential Personal Property 0 Other (Explain): 6 List any essential personal property, like cash, eyeglasses, or clothing that needs to be replaced because of this crime. or none. skip to 7.) Describe what was lost/damaged: Cost Describe what was lost/damaged: Cost 1. S 3. 2. 4. 6. $ Homeowner/Renter Insurance Company Policy or ID 0 Deductible Auto/Other Insurance Company Policy or ID Deductible $ — If there were no injuries and you are only asking for essential personal property benefits, skip to 15. — 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 employer, 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? 0 Yes 0 No (If No, skip to 8.) Did 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 federal tax return and all schedules.) Employer's Name, Address, and Phone #: Employer Street City State Zip Code Phone # Other Employer's Name. Address, and Phone #: Employer Street City State Zip Code Phone I Name, Address. and Phone # of doctor who certified victim could not go to work: Doctor Street City State Zip Code Phone N 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 ID St or 'None' Polley or ID r$ or -None 1. Unemployment Insurance 5. Waiters Compensation 2. Disability Insurance 6. Other insurance 3. Pension Plan 7. Social Secunty Benefits (ssn SSN required) • •_ 4. Other insurance 8. 551 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 Minot expenses, and a photocopy of the Death Certificate, if you have them. Name of Funeral Home: Phone 0: Address: Rev. September 2015 Page 2 of 4 EFTA00038439 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? ❑ Yes ❑ 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 # 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. (If none. skip to 11.) Name Social Security # Date of Birth Relationship to Victim Dependent Address Are ycu the legal guardian? ❑ Yes ❑ No Name Social Security It Date of Birth Relationship to Victim Other Dependent Address Are you the legal guardian? ❑ Yes ❑ No Name Social Security # Date of Birth Relationship to Victim Other Dependent Address Are you the legal guardian? ❑ Yes ❑ No 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.) Who received counseling? Relationship to Victim Insurance company billed for counseling Policy or ID # Counselor's name, address and phone #: Who else received counseling? Relationship to Victim Insurance company billed for counseling Policy or ID # 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. ❑ 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 P. Policy or ID a Name of person(s) covered by this insurance: Pnmary 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 of 4 EFTA00038440 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 # Policy or ID N Life Insurance Pension Plan Other Insurance/Plan Medicaid Workers' Compensation 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. 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: S 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 cwe now? Savings, stocks, bonds .$ If none, enter zero (0). Real Property (house, etc.) .$ MoLtgage S Proceeds from life insurance $ t Loans S 15 Is a private lawyer (not DA) representing you? O Yes O No If Yes: O OVS Claim O Civil Suit D Both 1. . Lawyer's Name Address Phone e 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 # 17 Victim/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 cnme, 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 NAP) in order for the VAP to assist the OVS in processing my claim and making its determinabon. 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 himfher to act as my representative. I understand a separate Notice of Appearance from my lawyer will be needed in addi 'en t. thr th ' n If I mi m rfri n. . •h r • l in.) ; rt. . um • • I al.r• . • ••I • d it ill a' i'd MOO ,ai.n • omen Interpreter Needed: 0 Yes )3 7Ne 0 Russian O Other 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. Mall 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 EFTA00038441 OCA Official Form No.: 960 11111111 . AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 PAM, 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). 1 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 slate 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 arc responsible for protecting my rights. 3. 1 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 WITII 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 122104002 9(a). Specitic information to be released: 0 Medical Record from (insert date) to (insert 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. CI Other: include: (Indicate by Initialing) Alcohol/Drug Treatment Mental Health Information Authorization to Discuss Health Information HIV-Related Information (b) 0 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 (Attorney/Firm Name or Governmental Agency Name) 10. Reason for release of information: II. Date or event on which this authorization will expire: At request of the individualfor purposes ofestablishing This authorization will expire upon the termination of the eligibility for 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: * Human Immun eficiency 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. EFTA00038442