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
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