12-Attachment D - Sexual Assault Forensic Examination Program Fast Track Reimb Form.pdf

Revised 7/6/2023

Sexual Assault Forensic Examination Program Fast Track Reimbursement Form

Utah Office for Victims of Crime

Victim Name: ____________________________________ Gender: _____________ Date of Birth: _________________________

Address: _____________________________________________________________ Phone: ______________________________

Medical Insurance Provider: _____________________________________________ Policy Number: _______________________

Law Enforcement Agency: ______________________________________________ Crime Date: __________________________

Law Enforcement Case Number: _________________________________________

Did crime occur in Utah? Yes No If not, where? _________________________________________________________

Provider Name and Address: ________________________________________________ Date of Service: ___________________

Was a full Sexual Assault Forensic Exam with Photo Documentation completed? Yes No

Describe any additional physical injuries resulting from the crime: ____________________________________________________

A separate Compensation Application for the Crime Victims Reparations Program must be completed for consideration of payment for services to treat the injuries listed above.

A copy of the itemized billing including current procedural codes, along with this form, must be submitted within one year of the examination. Please consider all other collateral sources before submitting a request for payment to UOVC. The director can make exceptions in extenuating circumstance cases. Submit to:

Utah Office for Victims of Crime

350 East 500 South Suite 200

Salt Lake City, Utah 84111

FAX: (801)533-4127

Email: crimevictims@utah.gov

PLEASE NOTE:

Reimbursement can be made only if the Sexual Assault Examination was reported to law enforcement. Please make every effort to provide the law enforcement case number. This form must be signed by the law enforcement officer, a victim/witness coordinator or the medical provider if the law enforcement case number is not available.

Services may only be paid under the Sexual Assault Forensic Examination Program when the victim is determined to be eligible under Statute 63M-7-509(1)(b)(i): the criminally injurious conduct occurred in Utah; or (ii) the victim is a Utah resident who suffers injury or death as a result of criminally injurious conduct inflicted in a state, territory, or country that does not provide a crime victims’ compensation program.

I hereby certify that the above-named victim received a sexual assault forensic examination performed by the provider listed above:

Signature: __________________________________________________________ Date: _____________________

Title: ______________________________________________________________

Attachment D