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Results for: crime victims compensation
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Crime Victims Compensation Program Initial Response and Assessment: Form I
Used by the clinical provider to get approval to see a victim for six sessions or less. If more than six sessions, please complete Form II (F800-081-000).

Form
F800-080-000
 
Crime Victims Compensation Program Initial Response and Assessment: Form II

Used by the clinical provider to request authorization to provide more than six sessions. This form must be submitted by the sixth session. (6 pages)



Form
F800-081-000
 
Crime Victims Compensation Program Progress Note: Form III

Used by the clinical provider to submit a request for preauthorization for payment of additional sessions.



Form
F800-082-000
 
Crime Victims Compensation Program Treatment Report: Form IV

Used by the clinical provider to request preauthorization for payment of additional sessions.



Form
F800-083-000
 
Crime Victims Compensation Program Treatment Report: Form V

Used by the clinical provider to get preauthorization for payment of additional sessions.



Form
F800-084-000
 
Crime Victims Compensation Program Termination Report: Form VI

Used by the clinical provider to inform L&I that you are no longer conducting treatment to the client. This must be submitted within 60 days of the client's last session and you are no longer conducting treatment.



Form
F800-085-000
 
Provider Change Form for Crime Victims Compensation

Providers use to inform L&I that they have changes to their account. Such as changes to their Tax ID address/name, business address, billing address, name, or termination of account. This also includes a W-9 form.



Form
F800-089-000
 
Billing Guidelines for Sexual Assault Examinations: Crime Victims Compensation Program

Provides information health-care providers need to bill the Crime Victims Compensation Program for medical services.



Manual
F800-100-000
 
Helping Providers Understand the Crime Victims Compensation Program
Fact sheet: Answers questions doctors and mental health counselors may have about the Crime Victims Compensation Program and billing for services. Also suggests steps these providers can take to speed up reimbursement.

Publication
F800-102-000
 
Your Independent Medical Exam (IME): Crime Victims Compensation Program
Fact Sheet: Provides answers to commonly asked questions about independent medical exams (IMEs) and contact information. Includes a form for requesting travel-related reimbursement for attending an IME.

Publication
F800-115-000
 
Help for Crime Victims/Ayuda para Víctimas de Crimen (English/Spanish)

Pamphlet/booklet: Answers questions about Washington State's Crime Victims Compensation Program, who may be eligible for benefits and how to apply.



Publication
F800-006-909
 
Statement for Crime Victims Mental Health Services

Used by the Crime Victims Compensation Program providers for reimbursement of Mental Health Services.



Form
F800-025-000
 
Help for Crime Victims (large poster)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. The size is 11" X 17" if ordered from the Crime Victims Compensation Program. If you print from the Web, the poster will be 8.5" X 11".

Poster
F800-041-000

Alt Language(s):
Español
 
Help for Crime Victims (large poster) - Spanish (Ayuda para Victimas de Crimen)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. The size is 11" X 17" if ordered from the Crime Victims Compensation Program. If you print from the Web, the poster will be 8.5" X 11".

Poster
F800-041-999

Alt Language(s):
Inglés
 
Crime Victims Statement for Pharmacy Services

Used by Crime Victims Compensation Program providers to bill for pharmacy services. Crime Victims Compensation Program providers are required to bill using this form.



Form
F800-058-000
 
Crime Victims' Statement for Compound Prescription

Bill form for use by pharmacies and home infusion companies to submit compound drug charges for Crime Victims Compensation. This form is for drug charges only and is filled out by the pharmacist.



Form
F800-067-000
 
Crime Victims Statement for Home Nursing Services

Used by the Crime Victims Compensation Program providers for reimbursement of home nursing services. Crime Victims Compensation Program providers are required to bill using this form.



Form
F800-070-000
 
Know What to Expect: How Recoveries and Settlements May Impact Your Crime Victim Claim

Pamphlet and form: Explains third-party liability, recoveries and settlements. A crime victim or the Crime Victims Compensation Program may pursue monetary restitution from someone who caused or contributed to a crime victim's injury. Explains the purpose of the form and why individuals who file a crime victims claim are required to complete it.



Publication
F800-074-000
 
Crime Victim Compensation Program Sexual Assault Exam Report

A form used by physicians, hospitals and clinics to provide information and reporting to the Crime Victims Compensation Program.



Form
F800-098-000
 
Help for Crime Victims (small poster)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. This poster is 8.5" X 11."

Poster
F800-104-000

Alt Language(s):
Español
 
Help for Crime Victims (small poster) - Spanish (Ayuda para Victimas de Crimen)
Poster: Provides contact information for the Crime Victims Compensation Program. Intended for display in health-care, criminal-justice and social-service organizations that assist crime victims. This poster is 8.5" X 11."

Poster
F800-104-999

Alt Language(s):
Inglés
 
Mental Health Fee Schedule and Billing Guidelines

Manual: This manual is for providers who bill the Crime Victims Compensation Program for mental health services for crime victims.



Manual
F800-105-000
 
CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.
Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Form
F800-116-000
 
Crime Victims Direct Entry Billing Manual
Instructions for completing a Direct Entry bill to submit to the Crime Victims Compensation Program. Direct entry allows you to submit or adjust bills using a free online billing form through Provider Express Billing (PEB).

Manual
F800-118-000
 
Hotline Tips for Medical Services Providers
Fact sheet: Provides tips to help medical service providers quickly obtain answers to claims and billing questions. Introduces L&I's Provider Hotline, Interactive Voice Response Message System and online Claim & Account Center.

Publication
F248-040-000
 
Application to Reopen Crime Victim Claim Due to Worsening of Condition

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.



Form
F800-031-000

Alt Language(s):
Español
 
Application for Benefits - Crime Victims

Used by victims of a crime in Washington State to receive benefits for time lost from work, loss of financial support, medical or mental health treatment. The Spanish version of the instructions are online as F800-042-999.



Form
F800-042-000

Alt Language(s):
Español
 
Request for Survivor Counseling Benefits (English/Spanish) Solicitud para Beneficios de Apoyo para los Sobrevivientes  

Used by immediate family members of homicide victims to request mental health counseling.



Form
F800-057-909
 
Crime Victims Provider's Request for Adjustment

Used by providers to request an adjustment to their bill if their entire bill was paid in error, or if a portion of the bill was overpaid or underpaid. Attach required reports and/or documentation to support the request.



Form
F800-064-000
 
Statewide Payee Registration and W-9 Form Crime Victims

Used by a provider assisting victims of crime to obtain a taxpayer ID number. Note: Register now for direct deposit available January 2013.



Form
F800-065-000
 
Statement for Crime Victim Miscellaneous Services

Used by the provider or supplier for reimbursement of the following services - dental, glasses, home health, nursing home serivces, medical equipment, prosthetics-orthotics, transportation, vocational, retraining and other.



Form
F800-076-000
 
Travel Reimbursement Request - Crime Victims
If you are considered a victim of crime, use this form to track your travel expenses for medical, retraining or vocational services or for an independent medical exam. You should have approval from your claim manager before you travel.

Form
F800-049-000
 
Application to Reopen Claim - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición

Benefits are limited to $50,000 per claim. if your claim has met or exceeded this cap, your reopening application will be denied and we will be unable to pay any further benefits. Used by victims of crime and medical or mental health providers to request a claim be reopened.



Form
F800-031-999

Alt Language(s):
Inglés
 
Victim Verification Form

For use by crime victims requesting wage replacement compensation



Form
F800-110-000

Alt Language(s):
Español
 
Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo

Crime Victim Worker Verification - Spanish - Formulario de Verificación de Empleo



Form
F800-110-999

Alt Language(s):
Inglés
 





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