OFFICE OF MEDICAL ASSISTANCE PROGRAMS recipient statement form 1. recipient's ma number 2. recipient's name 4. recipient's address: 3. birth date check one box below: 5. o o i certify that i am the survivor of rape or incest and that i did not report the crime to law enforcement authorities or child protective services. i certify that i am the survivor of rape or incest and i reported the crime, together with the name of the offender (if known), to: __________________________________________________________ 6. date of report (if known): i understand that any false statements made above are punishable by law and that false reports to law enforcement are punishable by law. 7. ____________________________________________________ siGnature of patient 8. _____________________ date all information will be kept confidential American LegalNet, Inc. www.FormsWorkFlow.com ma 368 4/10