Fill and Sign the Mt Rape Form

DEPARTMENT OF JUSTICE OFFICE OF VICTIM SERVICES Forensic Rape Examination Payment Program Claim Form INSTRUCTIONS: Use this form when a medical provider is billing the Department of Justice, Office of Victim Services, for reimbursement of costs associated with providing a forensic rape examination. (1) Fill in all blanks on this form (3) Mail the completed form and all attachments to: Office of Victim Services (2) Attach an itemized bill including Attn: FREPP HCFA form with CPT codes and notes 2225 11 th Avenue Helena, MT 59601 All Sections MUST be completed. PLEASE PRINT. SECTION ONE: VICTIM INFORMATION (TO BE COMPLETED BY MEDICAL PROVIDER) Date of Crime Location of Crime (City) (County) (State) Victim’s Name Address Date of Birth Social Security Number Date mailed to FREPP Forensic Rape Examination Kit Number SECTION TWO: PROVIDER INFORMATION (TO BE COMPLETED BY MEDICAL PROVIDER) Federal I.D. Number Date of Forensic Exam Facility Provider Name License # Address Billing Department Contact Person Phone Number The medical provider understands that the $600 payment it receives from the Office of Victim Services constitutes payment in full for performance of the forensic rape examination and that the provider may not bill the victim for covered costs associated with the exam that exceed the allowable payment of $600. SECTION THREE: VICTIM INSURANCE WAIVER (TO BE COMPLETED BY VICTIM/GUARDIAN) I have been advised of the options of payment for the forensic exam. I understand that I may use private insurance benefits, including Medicaid, Medicare, HMO or any other insurance program, for payment for the forensic exam. I choose not to use my private insurance benefits but request that the hospital submit directly to the Office of Victim Services for payment. However, I also understand that if I have sustained physical injuries that my insurance company or myself may be responsible for those charges. Victim/Guardian Name (Print or Type) Victim/Guardian Signature Date Medical Examiner Name (Print or Type) License # Medical Examiner Signature Date If you have questions, call the Department of Justice, Victim Services Program at (406) 444-3653. OVS # 10 (5/07)