Rpf - august 201

MARY VAIL WARE
DIRECTOR
Post Office Box 26927 Richmond, VA 23261 800.552.4007 877.377.5164 (Fax) SAFE (SEXUAL ASSAULT FORENSIC EXAM) PAYMENT PROGRAM
REQUEST FOR PAYMENT FORM
INSTRUCTIONS
All sections of this form must be completed as applicable for each date of service. Payment policies and detailed
instructions for completing this form may be found at www.cicf.state.va.us/forensic_exams. Please send both pages of this form,
along with a detailed itemized bill and Explanation of Benefits (if applicable), within one (1) year from the date of service, to:
SAFE Payment Program P.O. Box 26927, Richmond, VA 23261 Fax: (877) 377-5164 Email: forensicpayments@cicf.virginia.gov SECTION 1 - FORENSIC EXAMINER VERIFICATION
A. I have conducted a forensic examination on a victim of a sexual crime for the purpose of collecting medical evidence to aid in the current or ultimate investigation and prosecution of this crime in the Commonwealth of Virginia. B. I understand that by not completing this form accurately and in its entirety, payment delay and/or denial will result. C. Exam Type (please select one): I utilized Physical Evidence Recovery Kit (PERK) number ________________ and released it to: the law enforcement agency or other (location and reason required)__________________________________________________________ I did not use a PERK and the exam was authorized by the following law-enforcement official or prosecutor. Name/Title (required): ________________________________________________________________________________ I performed a follow-up exam to forensically document the healing of injuries and/or differentiate initial findings that was requested and authorized by the following law-enforcement official or prosecutor. Name/Title (required): _____________________________________________________ Initial DOS: ________________ _________________________________________________________________ _____________________________________________ Forensic Examiner Name/Title/Phone Number ________________________________________________________________________________________________________________________ Facility Name/Billing Address __________________________________________________________________ _____________________________________________ SECTION 2 - PATIENT INFORMATION
_____________________________________________________ ______________________________________________________________ Patient Name – First, Middle Initial, Last (or patient label) Address (OPTIONAL - for payment notification and information about payment of other crime-related expenses) _______________________ _______________ _____________ ______________________________________________________________ ______________________________________________________ ______________________________________________________________ Parent/Legal Guardian present with patient (if patient is a minor) Billing Method (please select one):
Patient is covered by a federally-funded insurance (Medicaid, Medicare, Tricare, Veterans’ Administration, etc.),
which MUST be billed first, and would like the SAFE Payment Program to pay any unpaid eligible out-of-pocket
expenses. Please list insurance provider: ______________________________
Patient wishes for the provider to bill his/her private health insurance and would like the SAFE Payment Program to
pay any unpaid eligible out-of-pocket expenses. Patient wishes for the SAFE Payment Program to pay for all eligible examination-related expenses.
For questions, please contact the SAFE Payment Program at (800) 552-4007 or forensicpayments@cicf.virginia.gov. SAFE PAYMENT PROGRAM
Patient Name (or patient label) Date of Service REQUEST FOR PAYMENT FORM – PAGE 2

SECTION 3 - INCIDENT/EXAM INFORMATION

______________________________________________________
_______________________________________________________________ Date/Time of Crime (if unknown, please estimate if possible) Crime location (City/County – unknown is not acceptable) ______________________________________________________ _______________________________________________________________ Investigating Agency (if different from crime jurisdiction) Is this a restricted report or unreported crime (blind)? (PERK exams only) ______________________________________________________ _______________________________________________________________ Medical Record or Patient Account Number SECTION 4 - EXPENSES
Please indicate which expenses shall appear on the bill. Any services appearing on the itemized bill that are not indicated here will
be ineligible for reimbursement. This section may be omitted as long as exact equivalent documentation is provided, to include
forensic justification for additional labs or services.
PART 1 - GENERAL
Forensic examiner services fee, including all necessary equipment and supplies (may be itemized separately on bill) Physician fee for medical screening exam (not examiner fee) Ambulance transfer fee from a facility unable to complete the PERK Receipt for actual cost of shipping PERK to DCLS PART 2 - LABORATORY
Trichomonas/BV (Wet Prep/KOH/Urogenital culture) Pregnancy (Serum or Urine) Syphilis Hepatitis B or Hepatitis Panel HIV
PART 3 - ADDITIONAL LABS AND EXPENSES
A. The following laboratory studies are only considered eligible for payment by the SAFE Payment Program when conducted
for a specific evidentiary purpose:
Other (specify): _____________________________ Purpose: _______________________________________________ B. The following laboratory studies are only considered eligible for payment by the SAFE Payment Program
when conducted for the purpose of administering HIV post-exposure prophylactic medication:
CBC (complete blood count) Serum Chemistry (list specific labs to appear on bill) _______________________________________________________ Additional services necessary to conduct the forensic examination (specify and explain forensic purpose):
____________________________________________________________________________________________________
____________________________________________________________________________________________________

PART 4 - MEDICATIONS
Ceftriaxone (250mg) Azithromycin (1gm) Other (specify): _______________________________ HIV Prophylaxis: Specify type and dose:_________________________________________________________________ Emergency Contraception: Plan B (single or full dose) Other (specify): ______________________________________ One dose sedative/tranquilizer/antidepressant: Specify type and dose ________________________________________ Anti-emetic: Specify type and dose: ________________________________________________________________ NOTE: Tetanus immunization and pain medication are not eligible.
For questions, please contact the SAFE Payment Program at (800) 552-4007 or forensicpayments@cicf.virginia.gov.

Source: http://www.cicf.state.va.us/pdf/RPF.pdf