Instructions for the Victims' Compensation Board Gross Sexual Assault Forensic Examination Claim Form

Gross Sexual Assault Forensic Examination Claim Form (PDF)

Emergency Department Staff Instructions

CLAIM FORM SECTION 1: Patient information

  1. Kit Number: Attach one of the adhesive numbers from the kit or enter the kit number.
  2. Patient Tracking Number: Use this space to enter a number which will connect this forensic kit claim form to the appropriate patient and that patient's records. Usually an account number or a medical record number would work.
  3. At this time, we are not making use of the "Lot number" which may appear on the kit.

CLAIM FORM SECTION 2: Attending Medical Provider’s Attestation of Treatment and SAFE designation

  1. The description section is to give a general description of the services provided, not to list physical findings or a description of the crime. Please also complete the checklist of services, see Section 5.
  2. The attending medical provider performing the ER medical screening examination should enter his/her credential, signature, date, and printed name and title.
  3. Below, print the name and title for the health care professional performing the sexual assault medical/forensic examination. Enter the year in which the sexual assault examiner completed the 40 hour SAFE training course, or enter N/A if not a SANE or SAFE.
  4. Contact: Provide a name and telephone number for a contact person in the ED. We would call this person with questions on Sections 1, 2, 3, & 5, not with billing questions.

CLAIM FORM SECTION 5: Services/Charges. To be completed by ED staff.

  1. Check the “E.R. Physician or other professional fee” line when there is a separate charge for a physician or medical professional who performs either the emergency department screening examination or a forensic examination.
  2. Check “Emergency room, clinic, or office room fees” if there will be charges for the use of a facility.
  3. Check off all services provided, list and explain further testing, and name and match medications provided to the conditions treated. Comment further as necessary.

PLEASE PROVIDE PATIENT WITH VICTIMS’ COMPENSATION BROCHURE/APPLICATION CONTAINED IN KIT. A sexual assault victim who reports the assault to law enforcement is eligible to apply for reimbursement for losses or expenses, such as counseling costs (for the victim or a family member), lost wages, and medical expenses not part of the forensic examination. The hospital must bill Victims’ Compensation directly for charges related to the gross sexual assault forensic examination. Billing, Coding and Records Staff Instructions on back of Claim Form

Billing, Coding, and Records Staff Instructions

CLAIM FORM SECTION 4: Hospital/Facility - Billing, Coding, and Records staff:

  1. State Vendor Code Number: This is the State of Maine number for the facility, necessary for payment. This number should be in our system already and needs to be completed only if there has been a change. This is not the facility’s F.I.D. number. The facility’s vendor code information must be changed if the facility’s address is changed.
  2. Patient Tracking Number in Section 1: Make sure that a number, such as an account or medical record number, has been entered as a Patient Tracking Number in Section 1. This number is the only patient identifier which will appear on your payment check, the only number to connect the patient, charges, and payment.
  3. Contact: Please provide the name and telephone number for a person in the billing office whom we can contact if we need additional information. When possible, we will try to avoid denying or returning claims.
  4. Itemized bills and statements with individual CPT codes:
    1. There must be an itemized bill listing each service and medication by name.
    2. A bill form providing a CPT code for each service must be submitted.
    3. Please note that UB-92 forms can be used only if they list a CPT code for each service rather than consolidations under categories, e.g. “Laboratory Chemistry.”



  1. Single bill preference: In the vast majority of cases, we receive a single bill covering all services from a facility. In some cases, however, physicians bill separately. We urge hospitals and physicians to work together to devise a single billing process by which the facility would bill for all charges and disburse payments to other providers under whatever arrangement is satisfactory to the parties. The VCP will not make multiple payments on the same case.