NY Form 5020 2025

NY Form 5020: What You Should Know

Name and address of hospital (number, street, city, county, state, zip). 35. Name and address of health insurance carrier (number, street, city, state). 36. Name and address of AIDS Services Organization (number, street, city, state). 37. Name and address of state agency responsible for administering AIDS Services Organizations' programs (number, street, city, state, zip). 38. Name and address of public or private organization (organization's name and address). 39. Name and address of AIDS Service Organization (name, address, telephone, fax, e-mail). 40. Name and address of hospital (number, street, city, county, state, zip).  41. Name and address of insurance carrier (number, street, city, state). 42. Name and address of AIDS Services Organization (name, address, phone, fax, e-mail). 43. Affidavit of physician who performs AIDS services. Form 5020 (Rev7) June 2002. Filming this form is not an admission of liability. 27. Name, address and telephone number of physician who performs AIDS services. Form 5021 (Rev7) Dec 2011. Filming this form is not an admission of liability. 28. Name and address of HIV-infected individual (age, color, date of infection). 28-B. Affidavit of AIDS Services Organization to identify HIV-infected individual. Affidavit of AIDS Services Organization (letter) (2 sheets, color-coded, 8.5" wide by 5" high) (addressed to “General Counsel, AIDS Services Organization, NYS Department of Health”) Affidavit of AIDS Services Organization (letter, color-coded) (addressed to “Director of Legal Affairs, NYS Department of Health, NYS Division of Health” and “AIDS Services Organization, NY Department of Health, NYS Division of Health”). Form 5022 (Rev18) Jan 2012. Affidavit of AIDS Services Organization to identify HIV-infected individual. Affidavit of AIDS Services Organization (letter) (7 sheets, color-coded, 8.

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