Notice Of Rights For Victims Of Violent Crimes Form (Page 2 of 2) in pdf

Notice Of Rights For Victims Of Violent Crimes Form Page 2

As a crime victim, there are many resources available to you in _________ County:

(List local and state resources)

______________________________________________________________________________

Signed: _______________________ (victim)

Date: ___________________

Printed Name of Officer: ___________________________________________

Signature of Officer: ______________________________________________

Copies Given To:

______ Victim

______ Victim/Witness Advocate

______

Law Enforcement

MEDICAL RECORDS RELEASE

(if appropriate)

DOCTOR/HOSPITAL: __________________

ADDRESS: ___________________

_____________________________

PATIENT: ____________________________

ADDRESS: ___________________

_____________________________

DATE OF BIRTH: ______________________

DATE HOSPITALIZED: _________________

TYPE OF CRIME: _____________

I hereby authorize and request you to release the complete medical records in your possession

concerning my illness and/or treatment to: ___________________________________________

_________________________________________________(list local criminal justice agencies)

or any duly authorized representative of these agencies.

Signed: ________________________________ (victim) Date: __________________

I hereby request that all information be kept confidential pursuant to §44-3-311, M.C.A.

Signed: ________________________________ (victim) Date: __________________

OVS 1 (5/04)

Notice Of Rights For Victims Of Violent Crimes Form Page 2