Form I-60 "Dental Claim Form" - New York

What Is Form I-60?

This is a legal form that was released by the New York State Office of Victim Services - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the New York State Office of Victim Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form I-60 by clicking the link below or browse more documents and templates provided by the New York State Office of Victim Services.

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Download Form I-60 "Dental Claim Form" - New York

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*I-60*
CLAIM
STATE OF NEW YORK
NO.
OFFICE OF VICTIM SERVICES
AE Smith State Office Building,
MAY BE DUPLICATED
nd
80 South Swan Street, 2
floor
ALBANY, NEW YORK 12210-8002
TO BE COMPLETED BY
DENTAL CLAIM FORM
ATTENDING DENTIST
I.
1.
Name of victim:
2. Date of crime:
Victim’s Home Mailing Address:
4. Have you made application for services to Medicaid, Workers’
3.
Compensation, or any other insurance plan in relation to this
injury?
If yes, which one?
Yes
No
5.
What history of crime related injury did the victim give you?
6.
What is your diagnosis (include results of x-rays)?
7.
What is your prognosis?
8.
Do you believe this dental work is related to the crime as described in box 5?
Yes
No
Please explain.
1.
Dentist Name:
2. If Prosthesis
(If No, Reason for Replacement)
Date of Prior
II.
Yes
and/or Crown, is this
Placement
No
initial placement?
3.
Mailing Address:
4. Is this Treatment
If Services
Date Appliance
Mos. Treatment
for Orthodontics?
Already
Placed:
Remaining
Yes
5.
City, State, Zip Code
Commenced,
No
Enter:
6.
Dentist Tax Identification No.:
7. Dentist License No.:
8. I am a Specialist in:
Oral Surgery
Orthodontics
Periodontics
Endodontics
Other
9. Date of
Place of Treatment
Radiographic or
HOW
First
NO
YES
10. Check Only One:
Office, Hosp. Or Other
Model Enclosed?
MANY?
examination
DENTIST’S STATEMENT OF ACTUAL SERVICES: I
hereby certify that the procedures below were
rendered and completed on the dates indicated.
DENTIST’S TREATMENT PLAN (PRE-
11. Was condition related to victim’s employment?
Yes
No
DETERMINATION OF BENEFITS).
Was condition related to an Auto Accident?
Yes
No
_____________________________ ___________
Was condition related to Other Accident?
Yes
No
SIGNED (DENTIST)
DATE
12. What permanent effects, if any, do you anticipate?
13. Examination and Treatment Plan. List in Order from Tooth No. 1 through Tooth No. 32
DATE SERVICE
ADA
Crime
Description of Service
Tooth #
PERFORMED
Procedure
Related
Surface
Fee
(Including x-rays, prophylaxis,
or Letter
Code
materials used, etc.)
Mo Day Year
Y or N
TOTAL
FEE
CHARGED
*I-60*
CLAIM
STATE OF NEW YORK
NO.
OFFICE OF VICTIM SERVICES
AE Smith State Office Building,
MAY BE DUPLICATED
nd
80 South Swan Street, 2
floor
ALBANY, NEW YORK 12210-8002
TO BE COMPLETED BY
DENTAL CLAIM FORM
ATTENDING DENTIST
I.
1.
Name of victim:
2. Date of crime:
Victim’s Home Mailing Address:
4. Have you made application for services to Medicaid, Workers’
3.
Compensation, or any other insurance plan in relation to this
injury?
If yes, which one?
Yes
No
5.
What history of crime related injury did the victim give you?
6.
What is your diagnosis (include results of x-rays)?
7.
What is your prognosis?
8.
Do you believe this dental work is related to the crime as described in box 5?
Yes
No
Please explain.
1.
Dentist Name:
2. If Prosthesis
(If No, Reason for Replacement)
Date of Prior
II.
Yes
and/or Crown, is this
Placement
No
initial placement?
3.
Mailing Address:
4. Is this Treatment
If Services
Date Appliance
Mos. Treatment
for Orthodontics?
Already
Placed:
Remaining
Yes
5.
City, State, Zip Code
Commenced,
No
Enter:
6.
Dentist Tax Identification No.:
7. Dentist License No.:
8. I am a Specialist in:
Oral Surgery
Orthodontics
Periodontics
Endodontics
Other
9. Date of
Place of Treatment
Radiographic or
HOW
First
NO
YES
10. Check Only One:
Office, Hosp. Or Other
Model Enclosed?
MANY?
examination
DENTIST’S STATEMENT OF ACTUAL SERVICES: I
hereby certify that the procedures below were
rendered and completed on the dates indicated.
DENTIST’S TREATMENT PLAN (PRE-
11. Was condition related to victim’s employment?
Yes
No
DETERMINATION OF BENEFITS).
Was condition related to an Auto Accident?
Yes
No
_____________________________ ___________
Was condition related to Other Accident?
Yes
No
SIGNED (DENTIST)
DATE
12. What permanent effects, if any, do you anticipate?
13. Examination and Treatment Plan. List in Order from Tooth No. 1 through Tooth No. 32
DATE SERVICE
ADA
Crime
Description of Service
Tooth #
PERFORMED
Procedure
Related
Surface
Fee
(Including x-rays, prophylaxis,
or Letter
Code
materials used, etc.)
Mo Day Year
Y or N
TOTAL
FEE
CHARGED