Crime Victims Reparations Medical Expense Verification Form
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1CRIME VICTIMS REPARATIONS
MEDICAL EXPENSE VERIFICATION FORM
THIS FORM IS TO BE COMPLETED BY PROVIDER’S BUSINESS OFFICE
CVR NUMBER:
CLAIM INVESTIGATOR INSTRUCTIONS:
1) This form may be sent in lieu of phone verification of medical
VICTIM:
expense.
2) Send a copy of this form and the “Authorization To Release
Information “ to each medical provider listed on the claim form.
VICTIM SSN:
3) Attach the completed verification form(s) to the claim form and
checklist before forwarding to the CVR Board Office.
CLAIMANT:
MEDICAL PROVIDER INSTRUCTIONS:
DATE OF CRIME:
1) This form is to be completed by the business office.
Sheriff’s Claim Investigator:
2) A Crime Victims Reparations claim has been made under the Louisiana
Crime Victims reparations act at LA R.S. 46.1801-1822
by the above named victim for injuries sustained on the date shown.
Address:
3) The completed form is to be returned to the sheriff’s Claim Investigator at the
address shown.
4) The Louisiana Crime Victims Reparations Board does not act as guarantor for
any service rendered.
Phone:
5) Insurance payments must be credited before completion of this form.
TOTAL CHARGES FOR SERVICE TO DATE:
$ ___________
TYPE OF SERVICE:
PAID BY PATIENT:
___________
HOSPITAL
IN-PATIENT
PAID BY INSURANCE:
___________
PHYSICIAN
OUT-PATIENT
INSURANCE ADJUSTMENTS:
___________
DENTAL
OTHER
OTHER PAYMENTS(EXPLAIN ON BACK):
___________
CURRENT BALANCE
$ ___________
NAME AND ADDRESS OF PATIENT’S INSURANCE:
__________________________________________
POLICY NUMBER: _________________________
__________________________________________
GROUP NUMBER: _________________________
__________________________________________
PHONE NUMBER: ________________________
NAME AND ADDRESS OF POLICY HOLDER: _________________________________________________________________________
_______________________________________________________________________________________________________________
IF THE PROVIDER IS A HOSPITAL, ATTACH THE FOLLOWING DOCUMENT(S) TO THIS FORM:
* EMERGENCY TREATMENT AND * FINAL DISCHARGE REPORT
_____________________________________________________
____________________________________________________
AUTHORIZED SIGNATURE
BUSINESS NAME
_____________________________________________________
____________________________________________________
PRINTED NAME
ADDRESS
_____________________________________________________
____________________________________________________
TITLE
CITY, STATE, ZIP
_____________________________________________________
____________________________________________________
DATE
PHONE
FEDERAL EMPLOYER IDENTIFICATION NUMBER
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