Application For Payment Sexual Assault Victims' Emergency Medical Response Fund Form - Oregon Department Of Justice
ADVERTISEMENT
1
2Application for Payment
Sexual Assault Victims’ Emergency Medical Response Fund
Complete this side of the form only if:
- The victim wishes to bill the Fund for payment of medical assessment services and does not wish to bill
her/his health insurance coverage.
- The victim does not have health insurance coverage.
Please see the reverse side for other health insurance information.
To be filled out with victim:
Name: __________________________________________________________________________________
Address: ________________________________________________________________________________
Contact telephone: ______________________________________
Date of birth: _____________________
Date and time of sexual assault: Date:______________________ Time:
a.m./p.m.
City/County of assault: ____________________ Signature of victim: ________________________________
State Crime Victims’ Compensation Program has been explained to the victim: Yes
No
To be filled out by provider:
I have provided the service or services checked below:
Complete Medical Assessment
Medical examination plus collection of forensic evidence using the Oregon State Police SAFE Kit. OSP
SAFE Kit must be conducted no more than 84 hours (3_ days) after assault. Use of the kit must be
authorized by and the kit must be provided to the appropriate law enforcement jurisdiction.
*Amount billed: _______________ ($380 maximum; $455 maximum if examination conducted by a SANE.)
Law Enforcement Agency notified: Yes
No
Agency: ___________________________________
Emergency contraception dispensed. *Amount billed: ____________________ ($55 maximum.)
Dispensed by (business name): ___________________________________________________________
Sexually transmitted disease prophylaxis dispensed. *Amount billed: _______________ ($100 maximum.)
Partial Medical Assessment
Medical examination without forensic evidence collection. The medical examination must be conducted no
more than 168 hours (7 days) after assault.
*Amount billed: _______________ ($175 maximum; $250 maximum if examination conducted by a SANE.)
Emergency contraception dispensed. *Amount billed: ____________________ ($55 maximum.)
Dispensed by (business name): ______________________________________________________
Sexually transmitted disease prophylaxis dispensed. *Amount billed: _______________ ($100 maximum.)
Date and time of exam: ______________
a.m./p.m.
___________________________
Date
Time
Number of hours post-assault
_______________________________________________________
___________________________
Please print name and title
Please provide SANE
certification number if applicable
_______________________________________________________
___________________________
Nurse Examiner or Physician signature
Date
* MUST ATTACH INVOICE AND FILL IN AMOUNT BILLED PER SERVICE and send with this form to:
Sexual Assault Victims’ Emergency Medical Response Fund
Oregon Department of Justice, Crime Victims’ Assistance Section
1162 Court Street NE, Salem, OR 97301-4096
Page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal