Form I-50 "Attending Physician's Report" - New York

What Is Form I-50?

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-50 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-50 "Attending Physician's Report" - New York

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PLEASE RETURN TO THE LOCATION BELOW
*I-50*
New York State
Office of Victim Services
AE Smith State Office Building
nd
80 South Swan Street, 2
floor
Albany, NY 12210
(518) 457-8727
ATTENDING PHYSICIAN’S REPORT
1.
NAME OF INJURED VICTIM (Last, first, middle)
2.
HOME MAILING ADDRESS (Number, street, city, state, zip code)
3.
DATE OF CRIME (Mo, day, year)
4.
DOES THE VICTIM HAVE MEDICAL COVERAGE?
Yes
No (If yes, which plan)
5.
WHAT HISTORY OF CRIME RELATED INJURY DID THE VICTIM GIVE YOU?
6.
WHAT IS YOUR DIAGNOSIS (Include results of x-rays, laboratory tests, etc?)
7.
DOES THE VICTIM HAVE A HISTORY OF A PRE-EXISTING SIMILAR MEDICAL CONDITION OR A PRIOR INJURY TO THE AFFECTED
BODY AREA? IF SO, PLEASE EXPLAIN.
8.
DID THE INJURY EXACERBATE PRE-EXISTING CONDITIONS?
Yes
No IF YES, HOW LONG WILL THE EXACERBATION LAST?
9.
PLEASE IDENTIFY THE PERCENTAGE OF TREATMENT RELATED TO THIS CRIME.
10. ARE THE SERVICES RENDERED RELATED TO THE CRIME RELATED INJURIES AS DESCRIBED IN SECTION 5?
Yes
No
11. IS THE VICTIM IN NEED OF MEDICATION DUE TO THE CRIME RELATED INJURIES?
Yes
No IF YES, LIST ON BACK
12. DID INJURY REQUIRE HOSPITALIZATION?
Yes
No
13. IS ADDITIONAL HOSPITALIZATION
REQUIRED?
IF YES, DATE OF ADMISSION (Mo, day, year)
DATE OF DISCHARGE
Yes
No
14. CRIME RELATED OPERATIONS (If any, describe type)
15. DATE OF OPERATIONS PERFORMED
(Mo, day, year)
16. WHAT IS THE FREQUENCY AND DURATION OF RECOMMENDED
17. WHAT PERMANENT EFFECTS, IF ANY, DO YOU
TREATMENT:
ANTICIPATE?
18. WHAT (Other) TYPE OF TREATMENT DID YOU PROVIDE?
19. DATE OF FIRST EXAMINATION
20. DATES OF TREATMENT (Mo, day, year)
21. DATE OF DISCHARGE FROM
(Mo, day, year)
TREATMENT
(Mo, day, year)
22. DO YOU BELIEVE THE VICTIM
23. PERIOD OF DISABILITY (If termination date
24. DATE VICTIM ABLE TO RESUME
unknown – so indicate)
WAS DISABLED DUE TO THE
(Mo, day, Year)
(Mo, day, year)
CRIME RELATED INJURIES?
TOTAL DISABILITY:
FROM
TO
LIGHT WORK
Yes
No
PARTIAL DISABILITY: FROM
TO
REGULAR WORK
25. IF VICTIM IS ABLE TO RESUME WORK, HAS HE/SHE BEEN ADVISED?
Yes
No
If YES, FURNISH DATE ADVISED
26. IF VICTIM IS ABLE TO RESUME ONLY LIGHT WORK, INDICATE THE EXTENT OF HIS/HER PHYSICAL LIMITATIONS AND THE TYPE
OF WORK HE/SHE COULD REASONABLY PERFORM WITH THESE LIMITATIONS.
27. IS MEDICAL AND/OR VOCATIONAL REHABILITATION INDICATED?
Yes
No
PLEASE RETURN TO THE LOCATION BELOW
*I-50*
New York State
Office of Victim Services
AE Smith State Office Building
nd
80 South Swan Street, 2
floor
Albany, NY 12210
(518) 457-8727
ATTENDING PHYSICIAN’S REPORT
1.
NAME OF INJURED VICTIM (Last, first, middle)
2.
HOME MAILING ADDRESS (Number, street, city, state, zip code)
3.
DATE OF CRIME (Mo, day, year)
4.
DOES THE VICTIM HAVE MEDICAL COVERAGE?
Yes
No (If yes, which plan)
5.
WHAT HISTORY OF CRIME RELATED INJURY DID THE VICTIM GIVE YOU?
6.
WHAT IS YOUR DIAGNOSIS (Include results of x-rays, laboratory tests, etc?)
7.
DOES THE VICTIM HAVE A HISTORY OF A PRE-EXISTING SIMILAR MEDICAL CONDITION OR A PRIOR INJURY TO THE AFFECTED
BODY AREA? IF SO, PLEASE EXPLAIN.
8.
DID THE INJURY EXACERBATE PRE-EXISTING CONDITIONS?
Yes
No IF YES, HOW LONG WILL THE EXACERBATION LAST?
9.
PLEASE IDENTIFY THE PERCENTAGE OF TREATMENT RELATED TO THIS CRIME.
10. ARE THE SERVICES RENDERED RELATED TO THE CRIME RELATED INJURIES AS DESCRIBED IN SECTION 5?
Yes
No
11. IS THE VICTIM IN NEED OF MEDICATION DUE TO THE CRIME RELATED INJURIES?
Yes
No IF YES, LIST ON BACK
12. DID INJURY REQUIRE HOSPITALIZATION?
Yes
No
13. IS ADDITIONAL HOSPITALIZATION
REQUIRED?
IF YES, DATE OF ADMISSION (Mo, day, year)
DATE OF DISCHARGE
Yes
No
14. CRIME RELATED OPERATIONS (If any, describe type)
15. DATE OF OPERATIONS PERFORMED
(Mo, day, year)
16. WHAT IS THE FREQUENCY AND DURATION OF RECOMMENDED
17. WHAT PERMANENT EFFECTS, IF ANY, DO YOU
TREATMENT:
ANTICIPATE?
18. WHAT (Other) TYPE OF TREATMENT DID YOU PROVIDE?
19. DATE OF FIRST EXAMINATION
20. DATES OF TREATMENT (Mo, day, year)
21. DATE OF DISCHARGE FROM
(Mo, day, year)
TREATMENT
(Mo, day, year)
22. DO YOU BELIEVE THE VICTIM
23. PERIOD OF DISABILITY (If termination date
24. DATE VICTIM ABLE TO RESUME
unknown – so indicate)
WAS DISABLED DUE TO THE
(Mo, day, Year)
(Mo, day, year)
CRIME RELATED INJURIES?
TOTAL DISABILITY:
FROM
TO
LIGHT WORK
Yes
No
PARTIAL DISABILITY: FROM
TO
REGULAR WORK
25. IF VICTIM IS ABLE TO RESUME WORK, HAS HE/SHE BEEN ADVISED?
Yes
No
If YES, FURNISH DATE ADVISED
26. IF VICTIM IS ABLE TO RESUME ONLY LIGHT WORK, INDICATE THE EXTENT OF HIS/HER PHYSICAL LIMITATIONS AND THE TYPE
OF WORK HE/SHE COULD REASONABLY PERFORM WITH THESE LIMITATIONS.
27. IS MEDICAL AND/OR VOCATIONAL REHABILITATION INDICATED?
Yes
No
LIST MEDICATIONS PRESCRIBED FOR CRIME RELATED INJURIES FROM BOX 11
THE OFFICE OF VICTIM SERVICES WILL REVIEW AND DETERMINE THE REASONABLENESS OF
RELATED MEDICAL EXPENSES SUBMITTED TO THE OVS FOR PAYMENT. PLEASE KEEP IN MIND
THAT THE OVS IS THE PAYER OF LAST RESORT. CONSEQUENTLY, ALL EXISTING INSURANCE
WHICH THE CLAIMANT HAS MUST BE EXHAUSTED PRIOR TO SUBMISSION TO THE OVS.
DATE OF
PLACE
CHARGES
FULLY DESCRIBE PROCEDURES MEDICAL SERVICES
SERVICE
OF
OR SUPPLIES FURNISHED FOR EACH DATE GIVEN
SERVICE
(EXPLAIN UNUSUAL SERVICES OR
CPT
*
)
CIRCUMSTANCES
PROCEDURE
CODE
31.
TOTAL
32.
AMOUNT
33.
BALANCE
28.
SIGNATURE OF PROVIDER
30.
HAS CLAIMANT PAID ANY
CHARGE
PAID
DUE
(I certify that the statement on the reverse applies to this bill and is
PART OF THE BILL?
made a part hereof.)
Yes
No
29.
DATE:
PROVIDER’S NAME, ADDRESS, ZIP CODE AND
34.
PROVIDER SOC. SEC. NO.
35.
TELEPHONE NUMBER
YOUR PATIENT’S ACCOUNT NO.
36.
37.
PROVIDER TAX I.D. NO.
4 – PATIENT’S HOME
7 – NURSING HOME
*
5 – DAY CARE FACILITY (PSY)
8 – SKILLED NURSING FACILITY
1 – INPATIENT HOSPITAL
6 – NIGHT CARE FACILITY (PSY)
9 - AMBULANCE
2 – OUTPATIENT HOSPITAL
3 – DOCTOR’S OFFICE
A – INDEPENDENT LABORATORY
B -- OTHER MEDICAL/SURGICAL
FACILITY
O – OTHER LOCATIONS
PLEASE NOTE: ALL BILLS FOR SURGICAL ROCEDURES MUST HAVE ACCOMPANYING OPERATIVE REPORTS
.
HAVE YOU MADE APPLICATION FOR SERVICES TO:
BLUE SHIELD
YES
NO
MEDICAID
YES
NO
WORKER’S COMPENSATION
YES
NO
ANY INSURANCE COMPANY
YES
NO
MEDICARE
YES
NO
IF “YES” TO ANY, PLEASE STATE THE FOLLOWING:
OTHER INSURANCE COMPANY
NAME AND ADDRESS
NAME AND ADDRESS
POLICY NUMBER
POLICY NUMBER
AMOUNT REC’D
AMOUNT REC’D
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