COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Assault Examination: Program No. Index Reimbursement Form Crime Victims Compensation Program : Calendar No. VICTIM INFORMATION Victim’s Name: Plaintiff(s) -against- Victim’s Address: City: : JUDICIAL SUBPOENA SSN: : State: : Telephone Number: Victim’s Date of Birth: ( - Zip: ) : Legal Guardian (if victim is a minor): Defendant(s) : ...................................................... Address (if different from victim): Insurance Company: Policy Number: I authorize the facility listed below to bill my private insurance or any other source of benefit available to me for the examination. I further authorizeTHE PEOPLE OF THE STATE OF NEW YORK this examination to be released to the Crime Victims Compensation my billing information and medical records relating to Program for payment consideration and to the prosecutor’s office for the purposes of securing restitution. TO Victim’s Signature (Legal Guardian, if victim is a minor) LAW ENFORCEMENT AGENCY INFORMATION Date Law Enforcement Agency: Report Number: GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ) , the Honorable at the Court Authorizing Law Enforcement Officer: Telephone Number: ( located at County of in room □ Adult on the Assault of □ Adult ,Rape , at , Sexual day 20 noon, and at any recessed Crime Type: Minor in the □ o'clock Sexual or adjourned date, to testify and give evidence as a witness in this actionAbuse part of the on the AUTHORIZATION: Reimbursement can be made only if the examination was authorized by a law enforcement official. Please include the law enforcement report number. TheYourenforcement officer must sign this form. If the officer is not a contempt of court and will make you liable to law failure to comply with this subpoena is punishable as available, non-commissioned law enforcement personnel or the medical provider may this subpoenaexamination was authorized by law enforcement.and all damages sustained as a the party on whose behalf certify that the was issued for a maximum penalty of $50 result of your failure to comply. I hereby certify that the above-named victim was authorized by law enforcement to receive a sexual assault forensic examination, which was performed by the provider listed below. Witness, Honorable , one of the □ Law Enforcement Officer Justices of the Court in County, day of , 20 □ Non-Commissioned Law Enforcement Personnel □ Medical Personnel □ Other: Name of Certifying Personnel Signature MEDICAL FACILITY INFORMATION Name of Medical Facility: Address of Medical Facility: Contact Person: (Attorney must sign above and type name below) Date Attorney(s) for Date of Service: City: State: Office and P.O. Address Telephone Number: ( Zip: ) Telephone No.: A copy of the itemized billing, insurance explanation of benefits (EOB), medical records, and the reimbursement form, must be submitted Facsimile make within one year of the examination. All other payment sources available to the victim mustNo.: payment prior to the program making payment on behalf of the victim. Submit to: E-Mail Address: Crime Victims Compensation Program No.: Mobile Tel. P. O. Box 83720 American LegalNet, Inc. Boise, Idaho 83720 www.USCourtForms.com (208) 334-6080 or (800) 950-2110 COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Crime Victims Compensation Program Index Sexual Assault Examination :Program No. Reimbursement Form : Instructions Calendar No. Please refer to the following instructions to assist you in completing the sexual assault examination reimbursement form. Please note that : this form is requesting payment for the forensic examinationPlaintiff(s) patient wishes to JUDICIAL SUBPOENA cost of crime only. If the request financial assistance for the related treatment, they must submit a standard Crime Victims Compensation Application for eligibility review. -against: VICTIM INFORMATION : Victim Name: Name of the patient receiving the examination. Social Security Number: fill In the Social Security number of the victim (if available). : Victim Address: The mailing address of the victim. Defendant(s) : Victim Date of Birth: Fill in the telephone number of the victim, or the legal guardian if the victim is a minor. ...................................................... Legal Guardian: The name of the legal guardian of the patient, if the victim is a minor. Address: The mailing address of the legal guardian if it is different from that of the victim. Insurance Company: The name of any third party payment source that may be available to the victim, i.e. Blue Shield, Medicaid, Medicare THE PEOPLE OF THE STATE OF NEW YORK or Indian Health Services. Policy Number: The number of the insurance policy or any other identifying moniker associated with the victim’s third party payment TO source. AUTHORIZATION TO RELEASE INFORMATION Signature of the Victim: The signature of the victim authorizing the medical provider to release copies of the bill for service, medical records and insurance information to the program. GREETINGS: Date: The date upon which the authorization to release information was signed by the victim. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court located at County of in room , on of 20 , at o'clock in the noon, and at any recessed Law Enforcement Agency: Namethe the lawday of enforcement agency, who is authorizing the examination. or adjourned date, to testify and give evidence as a witness the criminal investigation. Report Number: The law enforcement incident report number assigned to in this action on the part of the the Honorable LAW ENFORCEMENT AGENCY INFORMATION Authorizing Law Enforcement Officer: Name of the law enforcement officer who authorized the examination to be completed. Telephone Number: The business number to reach the law enforcement officer. Crime Type: Check the box that best describes the this subpoena is punishable as a contempt of court and will make you liable to Your failure to comply with alleged crime. AUTHORIZATION FOR EXAMINATION the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure The printed Name of Certifying Personnel: to comply. name of the law enforcement officer who authorized the examination. If the officer is not available, non-commissioned personnel of the law enforcement agency (i.e. Victim/Witness Coordinator, Public Information Officer), or Witness, Honorable , one of the Justices of the the physician performing the examination may certify that the examination was authorized by law enforcement. Please indicate the authorizing persons affiliation by checking the appropriate description. , 20 Court in County, day of Signature: The signature of the certifying personnel. Date: The date upon which the certification of authorization was signed. (Attorney must sign above and type name below) MEDICAL FACILITY INFORMATION Name of Medical Facility: Name of the medical treatment facility where the examination was conducted. Attorney(s) for Date of Service: The date that the sexual assault examination was performed. Address of Medical Facility: The mailing address of the medical facility that conducted the examination. Contact person: the name of the person to contact at the medical facility regarding billing questions or missing documentation. Telephone Number: The telephone number of the contact person. Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com