Sexual Assault Forensic Examination Reimbursement

Sexual Assault Examination Program Reimbursement Form Crime Victims Compensation Program VICTIM INFORMATION Victim's Name: _______________________________________________ SSN:_____-____-______ Victim's Address: ___________________________________ City: _____________ State: _______ Zip: ______ Victim's Date of Birth: ______________ Gender: Male Female Telephone #: (____)____________ Legal Guardian (if victim is a minor): __________________________________ Relationship: _______________ Address (if different from Victim): _______________________________________________________________ Do you have insurance? Yes Insurance Company: _______________________________________ Policy #: ________________________ Crime Type: Adult Sexual Assault Adult Rape Minor Sexual Abuse No Date of crime: ___________________ Location of Crime (City/State): _____________________________ Was a law enforcement report filed under the victim's name? Yes No Report #: __________________________ Law Enforcement Agency: ________________________________ I authorize the facility listed below to bill my private insurance or any other source of benefit available to me for the examination. I further authorize my billing information and medical records relating to this examination to be released to the Crime Victims Compensation Program for payment consideration and to the prosecutor's office for the purposes of securing restitution. ___________________________________________________ __________________________________ Victim's Signature (Legal Guardian, if victim is a minor) MEDICAL FACILITY INFORMATION Anonymous Report: Date Yes No Name of Medical Facility:______________________________________ ____ Date of Service: ________________ Address: _________________________________________ City: _____________ State: _______ Zip: ________ Contact Person:_________________________________________ _ Telephone Number: (____) ___________ A copy of the itemized billing, insurance explanation of benefits (EOB), medical records, and the reimbursement form, must be submitted within one year of the examination. All other payment sources available to the victim must make payment prior to the program making payment on behalf of the victim. Submit to: Crime Victims Compensation Program P. O. Box 83720 Boise, Idaho 83720-0041 (208) 334-6080 or (800) 950-2110 Revised 7/2011 American LegalNet, Inc. www.FormsWorkFlow.com