Medical Service Treatment Plan Form - Crime Victim Compensation Page 2
Download a blank fillable Medical Service Treatment Plan Form - Crime Victim Compensation in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Service Treatment Plan Form - Crime Victim Compensation with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
24) List the treatment and objectives relative to the victimization. Each goal should have an estimated
completion date.
5) Describe any issues that may increase or decrease the length of treatment or effectiveness of
services provided.
6) Date client entered treatment:
Number of visits or services provided to date:
7) Anticipated number of visits/sessions per week/month of on-going treatment:
Anticipated number of weeks or months of treatment:
8) Regular fee for itemized services: The Board will not consider a treatment plan without an estimated
cost of services:
9) Are there services which will be billed by another provider (ex. Anesthesia)? Please list those
services:
Once the Board has made an approval you will be notified via mail. The Board processes and issues
payments only once a month, therefore payment could take up to 30 days after receiving an itemized
bill/invoice. The Compensation Board makes payment towards medical bills at 80% of the balance due
(after insurance). We ask that you accept our payment as payment in full. If not, please inform the
patient that they will be responsible for any remaining balance.
Provider Signature
Date
Patient/Claimant Signature
Date
Updated 3/2014
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical