SAFE Request for Payment Form

Form Description

The Request for Payment Form is used by forensic nurse examiners to request payment for victim sexual assault forensic medical exams. It includes basic information about the incident, who is authorizing the forensic exam (if a physical evidence recovery kit was not provided), and itemizes the services rendered. These payments are made directly to the hospital or facility which rendered the services. Required to submit a request for payment for forensic examination-related expenses; instructions included.

Form Instructions

The medical provider who performed the forensic medical exam should complete this form.

Fax or mail to:
Virginia Victims Fund
P.O. Box 26927
Richmond, VA 23261
Fax: (804) 823-6907