Supplemental Compensation Application Form. This is a Ohio form and can be use in Attorney General Office Statewide.
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OHIO VICTIMS OF CRIME COMPENSATION PROGRAM Application for Supplemental Compensation If you or your family members are innocent victims of a violent crime, financial assistance may be available. For more information, call: Ohio Victims of Crime Compensation Program Attorney General’s Office th 150 E. Gay St., 25 Fl. Columbus, OH 43215 (614) 466-5610 Toll-Free Numbers: For Specific Case Information (800) 582-2877 For General Information (877) 584-2846 (877-5VICTIM) Also visit us at www.ag.state.oh.us American LegalNet, Inc. www.FormsWorkflow.com ELIGIBILITY CHECKLIST FOR SUPPLEMENTAL APPLICATION If you answer “yes” to all these questions, you may be eligible for help from this program. ❑ The claimant has incurred additional economic loss. ❑ The supplemental application is being filed within five years of the last decision by the Attorney General, a Court of Claims panel of commissioners, or judge of the Court of Claims. ❑ The claimant has previously been determined eligible to receive an award of reparations by the Attorney General or Court of Claims. ❑ The claimant and the victim have maintained eligibility from the time of the previous decision. ❑ The maximum amount of $50,000 has not yet been paid on the claim. WHO CAN GET HELP? The Ohio Victims of Crime Compensation Program helps victims with certain out-of-pocket expenses caused when people are physically injured, emotionally harmed, or killed by violent criminal acts. Program costs are paid entirely by criminal fines and not by Ohio’s taxpayers. WHO IS NOT ELIGIBLE? ✓ The offender. ✓ Anyone who engaged in a felony of violence or drug trafficking within 10 years prior to the crime that caused the injury or during the pendency of the claim. ✓ A victim or claimant who has been convicted of a felony within 10 years prior to the crime that caused the injury or during the pendency of the claim. ✓ An claimant who has been convicted of a child endangering or domestic violence offense within 10 years prior to the crime that caused the injury or during the pendency of the claim. ✓ Anyone injured while incarcerated and serving a sentence. WHAT ARE SOME COSTS THAT MAY BE PAID? ✓ Medical and related expenses. ✓ Counseling for family members of victims for specific crimes (up to $2,500 each). Maximum $7,500 per claim. ✓ Wages lost from not being able to work. ✓ Replacement services. ✓ Crime scene clean-up/repair for safety (up to $750). ✓ Evidence replacement (up to $750). ✓ Funeral expenses. Crimes on or after July 1, 2003 up to $7,500. ARE THERE LIMITS ON COMPENSATION? ✓ Yes. Compensation cannot be paid for stolen, damaged, or lost property, or for pain and suffering. ✓ Compensation is not paid for costs payable by other sources. ✓ The total award must be $50 or more before payment is made (for crimes on or after July 1, 2003.) American LegalNet, Inc. www.FormsWorkflow.com OHIO VICTIMS Of CRIME COMPENSATION PROGRAM SUPPLEMENTAL COMPENSATION APPLICATION THIS DOCUMENT IS A PUBLIC RECORD. EXCEPT FOR INFORMATION THAT IS PROTECTED BY STATE OR FEDERAL LAW, INFORMATION YOU PROVIDE ON THIS APPLICATION IS SUBJECT TO PUBLIC DISCLOSURE UPON REQUEST. (Please Type or Print Using Blue or Black Ink) ORIGINAL CLAIM NUMBER: V - SECTION 1: VICTIM INFORMATION Victim’s Name (First / Middle Initial / Last) Street Address City County State Social Security # Victim is/was: a. Zip Date of Birth ❑ male ❑ b. female ❑ single ❑ married ❑ separated ❑ Has the victim been arrested for, or convicted of, any felony within 10 years prior to the injury, or since the injury? Has the victim lived in any state other than Ohio in the past 10 years? Home Phone ( ) ❑ Yes ❑ No ❑ divorced widowed ❑ Yes ❑ No If yes, list each state Work Phone ( ) SECTION 2: CLAIMANT INFORMATION (If different than victim) Claimant’s Name (First / Middle Initial / Last) Street Address City County Social Security # Claimant is: a. State Date of Birth ❑ male ❑ b. female ❑ single Zip Relationship to victim ❑ married ❑ separated ❑ divorced Has the claimant been arrested for, or convicted of, any felony within 10 years prior to the injury, or since the injury? Has the claimant lived in any state other than Ohio in the past 10 years? ❑ Yes Home Phone ( ) ❑ widowed ❑ Yes ❑ No ❑ No If yes, list each state Work Phone ( ) SECTION 3: HOUSEHOLD INCOME If seeking payment of hospital bill(s), the following information is needed to determine eligibility for the Hospital Care Assurance Program. How many are in the household? What was the annual household income at the time of the hospitalization? $ American LegalNet, Inc. www.FormsWorkflow.com SECTION 4: MEDICAL TREATMENT AND OTHER CRIME-RELATED EXPENSES EXPENSES NOT CONSIDERED IN ORIGINAL APPLICATION Provide name, complete address, telephone number, and date(s) of service for each provider of service or expense. Name / Address / City / State / Zip (Area Code) Telephone No. Date(s) of Service SECTION 5: INSURANCE AND BENEFIT INFORMATION ALL BILLS MUST BE SUBMITTED TO THE INSURANCE OR BENEFIT PLAN BEFORE COMPENSATION IS CONSIDERED. Does the victim have any insurance or benefit plan to cover the listed expenses? If yes, check all boxes that apply and give details in the space provided. ❑ Employers / Union Group ❑ Insurance Plan ❑ Other ❑ Yes ❑ No ❑ Medicare ❑ Workers’ Compensation ❑ Medicaid ❑ Private Accident Health Plan ❑ Restitution or money from the offender ❑ Homeowner’s Insurance ❑ Auto Insurance Name of Insurance Company / Benefit Plan Street Address or P. O. Box City State / Zip Policy Holder’s Name Policy Holder’s Social Security No. Policy No. Group No. (Application continues on reverse side.) American LegalNet, Inc. www.FormsWorkflow.com SECTION 6: EMPLOYMENT INFORMATION (Complete for additional work loss since the original application.) Employer / Business Name (Area Code) Telephone No. Street Address City State / Zip Additional date(s) absent from work due to crime-related injuries Name of doctor certifying length of time off from work Doctor’s Street Address Doctor’s (Area Code) Telephone No. City / State / Zip Did you receive: ❑ Sick Pay ❑ Workers’ Compensation ❑ Other (Please specify) ❑ Disability ❑ Union or Fraternal Plan ❑ Food Stamps / Cash Grant SECTION 7: FUNERAL EXPENSES (Complete if filing for funeral expenses) Funeral Home Name and Complete Address Social Security Death Benefit? ❑ Yes ❑ No Life Insurance? Was there: ❑ Yes ❑ No SECTION 8: REPRESENTATION An attorney is not required to submit the application. If an attorney does help, he/she must sign the application. The attorney cannot charge for representation. Attorney’s Name Street Address City / State / Zip (Area Code) Telephone No. Fax Number Attorney’s Signature Attorney’s Social Security Number or Tax ID No. SECTION 9: SUBROGATION, AUTHORIZATION, AND SIGNATURE I understand that if I get money from any other source to cover the same expenses I get compensation for, I have to reimburse the state of Ohio that amount of money. I hereby authorize any person (including any physician, medical facility, or health care provider), organization, the Ohio Department of Job and Family Services, the appropriate county Department of Job and Family Services or Child Support Enforcement Agency (for purposes of child support enforcement), law enforcement agency, or government agency, upon request, to release to the Ohio Attorney General, the Court of Claims of Ohio, or to my attorney, a copy of any report, document, record, criminal record, or other information (including tax information or returns, or medical information) in any way relating to my claim for an award of reparations under the Ohio Victims of Crime Compensation Program. I understand that providing my Social Security number is voluntary, and that it may be used to obtain the aforementioned reports, documents, records, and information necessary to verify my eligibility for an award of compensation. I further understand that failing to provide my Social Security number may significantly impede the processing of my claim. I understand that medical records may contain information regarding care of psychiatric/psychological conditions, drug or alcohol abuse, HIV test results, AIDS, and AIDS-related conditions. I understand that disclosure of confidential information from medical records may be protected by state or federal law. If applicable, state law (R.C. 3701.243) and federal regulations (42 C.F.R. part 2) prohibit the Ohio Attorney General or the Court of Claims of Ohio from making any further disclosure of confidential information without my specific written consent or as otherwise permitted by such regulations. This authorization or a copy hereof shall be valid for a period of two years without any further consent by me. ____________________________________________________ __________________ Signature of person seeking compensation (or signing as the legal guardian of a minor) Date of signature AG-CVC 3/04 American LegalNet, Inc. www.FormsWorkflow.com AUTHORIZATION FOR USE OR DISCLOSURE OF INFORMATION ORIGINAL CLAIM NUMBER: V - PATIENT’S NAME: DATE OF BIRTH: SOCIAL SECURITY NUMBER: ADDRESS: CLAIMANT’S NAME: I, __________________________________________, hereby voluntarily authorize the disclosure of information from my health record. I authorize the disclosure or use of MY ENTIRE RECORD, exclusive of psychotherapy notes. This information is to be disclosed by any covered entity, including any physician, medical facility, health care provider, mental health care provider, insurance company, billing department, health care clearinghouse, health plan, or pharmaceutical entity, and is to be provided to the Ohio Attorney General, the Court of Claims of Ohio, or to my attorney. This information is to be used in any way necessary related to my claim for an award of reparations from the Ohio Victims of Crime Compensation Program. I understand that medical records may contain information regarding care of psychiatric/psychological conditions, drug or alcohol abuse, HIV test results, AIDS and AIDS-related conditions. I understand that I may revoke this authorization in writing submitted at any time to the Ohio Attorney General, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate two years from the date of my signature. I understand that the Attorney General is not a covered entity and is not subject to the privacy requirements of the Health Insurance Portability and Accountability Act of 1996. However, I understand that the Ohio Public Records Act (R.C. §149.43) prohibits the Attorney General or the Court of Claims of Ohio from making any further disclosure of confidential information without my specific written consent or as otherwise permitted by such regulations. This authorization complies with the requirements of 45 C.F.R. §164.508, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the HIPAA Privacy Rule. A photocopy or facsimile copy of this authorization release shall have the same effect as the original. ____________________________________________________ VICTIM’S/CLAIMANT’S SIGNATURE ________________ DATE ___________________________________________________________ CLAIMANT’S RELATION TO VICTIM Do not write in this space – For Internal Use Only Claim Number: American LegalNet, Inc. www.FormsWorkflow.com Please mail completed application to: Ohio Victims of Crime Compensation Program Office of the Ohio Attorney General 150 E. Gay St., 25th Floor Columbus, OH 43215-4321 American LegalNet, Inc. www.FormsWorkflow.com