Medical Service Treatment Plan Form - Crime Victim Compensation

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Crime Victim Compensation
Medical Service
Seventeenth Judicial District
Treatment Plan
1000 Judicial center drive, suite 100
Brighton, CO 80601
Phone: 303-835-5615
Fax: 303-835-5575
Prior approval for crime related medical treatment and/or submission of this form does not
guarantee payment of additional medical services. You will be notified by mail of all Board
decisions. All treatment costs exceeding the approved amount determined by the Board are the
responsibility of the claimant. This form may be emailed to you for convenience. Handwritten forms
will not be processed and will be returned.
Provider Information
Client/Claimant Information:
Name/Practice Name:
Business Address:
Telephone Number:
Telephone Number:
Fax Number:
Please indicate what type of services this treatment plan includes:
___Chiropractic Care
___Physical Therapy
___Occupational Therapy
___Massage Therapy
1) Will your client’s private insurance cover your services? ______________
If not, please write N/A next to the insurance information below. If so, C.R.S. §24-4.1-110 requires that Victim
Compensation funding be used as a last resort. Thus, it is required that providers bill the insurance company first. Then,
figure out the co-payment amount or amount that will not be covered and write your treatment plan request accordingly. If
approved, you will be paid at 80% of the total balance billed after insurance has made payment.
Insurance Information
Telephone Number:
Fax Number:
Policy Number:
Group Number:
2) Briefly, describe the injuries of your patient, how they were caused by the crime:
3) Was the client a patient of yours before the criminal incident? If so, how might you differentiate the
pre-existing symptoms from those related to the crime?
Updated 3/2014


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