SAFE Payment Program

Sexual Assault Forensic Exam
In Virginia, victims of rape or sexual assault have the right to seek evidence collection at no cost; and have the right to have evidence collected through a Physical Evidence Recovery Kit (PERK) without filing a police report. Costs associated with evidence collection may include:
  • Emergency room physician fees
  • Hospital and forensic examiner fees
  • Testing for sexually transmitted infections and/or pregnancy
  • Medications to prevent sexually transmitted infections and/or pregnancy
  • Ambulance fees for the patient to be transported by ambulance to a medical facility for the forensic examination
  • Follow-up medical forensic examinations

Healthcare providers should bill the SAFE Payment Program directly. Victims should only receive a bill if they decided not to have evidence collected, or they received care or treatment not included in the list above. For questions about billing or eligibility, please call 1.800.552.4007.

Download SAFE Prescription Voucher

If the healthcare provider determines that a victim should take medication to prevent HIV, the SAFE Payment Program can help by paying for the following:
  • The full course (28-day supply) of HIV preventative medication
  • Anti-nausea medication (up to a 30 day supply)
  • Specific and limited follow-up medical care while taking the medication

The healthcare provider will help the patient locate a pharmacy to obtain the medication and provide a voucher for reimbursement to give to the pharmacy and follow-up medical care provider.


If the victim chooses not to report the crime, the PERK will not be tested and will be stored for a minimum of 2 years.

If, and when, the victim does report the crime, the police will take custody of the PERK and send it to the forensic lab within 60 days for testing. The victim has the right to request the status and results of the testing. Victims should make sure to keep their contact information up to date with the investigator and/or Commonwealth’s Attorney assigned to their case.

For more information regarding storage and testing of evidence, please visit the Department of Forensic Science website.


The SAFE Payment Program pays for costs associated with the collection evidence through a medical forensic examination conducted on victims of sexual assault per § 19.2-165.1. Forensic exams conducted for any other purpose or crime should be submitted to the Supreme Court of Virginia. Please contact Fiscal Services within the Office of the Executive Secretary of the Supreme Court of Virginia at 804.786.6455 for further information.

SAFE Payment Program Eligibility Requirements:
  • The crime occurred within the Commonwealth of Virginia.
  • Collection of evidence took place as outlined in §19.2-165.1 of the Code of Virginia.
    • Patients are not required to report the crime to law enforcement, nor cooperate with an investigation in order to request a Physical Evidence Recovery Kit (PERK) exam or for that exam to be paid per §19.2-165.1 (B).
    • If the patient declines evidence collection, the claim is not eligible for reimbursement. The SAFE Payment Program does not reimburse for consults, only for collection of medical forensic evidence.
  • Medical forensic examinations for non-acute (more than 120 hours after the crime) and/or chronic sexual abuse cases require authorization by law enforcement officer or prosecutor for payment per §19.2-165.1 (A).
    • Referrals from physicians, parents, and social workers do not meet the authorization requirements outlined in §19.2-165.1 (A) of the Code of Virginia.
  • Required documentation is submitted within one year from the date of service.


  • Complete Request for Payment Form
  • Gather Necessary Documentation:
    • Insurance explanation of benefits paid and/or denied, if applicable. If the patient is covered by a federally funded insurance such as Medicaid, Medicare, Tricare, etc., insurance must be billed primary. Billing private health insurance primary is not required unless requested by the patient. The SAFE Payment Program will pay any eligible remaining patient responsibility.
    • Itemized, detailed billing statement. Health insurance claim forms may not be considered alone.
Please submit the required documentation via one of the following:

IMPORTANT: Per §19.2-368.5:2 and §19.2-368.11:1(F) of the Code of Virginia, the patient may not be placed into collections once this form is filed with VVF.

Request for Payment Form
SAFE Payment Program Procedures and Guidelines
How to Submit a SAFE Claim


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.

View/Download SAFE Request for Payment Form

The SAFE Payment Program will provide a pre-paid PERK shipping label to send anonymous PERKs to the Division of Consolidated Laboratory Services (DCLS) in accordance with §19.2-11.6.

To obtain a pre-paid label, forensic providers should send an email request to The return mailing address must be included in the email.
Please include "PERK Shipping Label" in the subject line of your email.

Label requests will be responded to Monday through Friday during normal business hours. This excludes weekends, holidays and closings for inclement weather or other reasons.

Instructions and forms for shipping PERKs to DCLS