Forms

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If the victim has received 10 initial sessions of mental health treatment, verified by the Mental Health Treatment Form, and they need additional care, the counselor or psychiatrist fills out the Additional Treatment Form for additional sessions. Each time this form is completed, it allows for 10 sessions of treatment.

 

Virginia law states that the Virginia Victims Fund is the payer of last resort. This statute requires claimants to exhaust all available collateral resources before VVF can make payment. The resources relevant in each claim depend on both the crime type and the resources available to the victim. Advocates, victims, and Commonwealth Attorneys can use this checklist to help identify relevant insurances and resources in a case. This information will help guide the gathering of claim documentation necessary for payment.

 

The Employer Report Form verifies that the victim or a victim’s guardian has missed work due to crime related injury or counseling.

 

The Mental Health Treatment Form is used by counselors or psychiatrists to verify the care they are providing is related to the crime incident. Once completed, this form will allow for payment of the first ten sessions of a trauma-informed treatment plan.

 

The Notarized Authorization is essential to the claims process. Without a properly notarized authorization, the Virginia Victims Fund cannot begin to process a victim’s Claim Form for benefits. The Notarized Authorization allows VVF to collect documents on the victim’s behalf to help satisfy claim requirements. It also includes an acknowledgement of the terms of use, including an agreement for VVF to pay providers on the victim’s behalf, an acknowledgement that the victim will receive benefits from the fund in place of direct restitution payments from the offender, and an acknowledgement that if the victim receives benefits for expenses that VVF has paid from any other source, they must immediately repay the award. An oath that the information included in the Claim Form is correct and truthful is also included.

 

Public information about payment of sexual assault medical forensic examinations.

 

The Virginia Victim Fund protects claimants’ information by verifying all callers. VVF staff will only discuss claims with third parties that are authorized by the claimant in this form.

 

The Police/Sheriff Report Form is sent to law enforcement to request information necessary to VVF eligibility determinations.

 

The Restitution Payment Form can be used to send individual unclaimed restitution payments, or to send in a restitution payment on a claim paid out by VVF.

 

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.

 

The Travel and Appointment Verification Form is used to demonstrate the miles traveled to and from medical appointments related to the crime.

There is a special exception which allows for parents or guardians of child victims to claim the miles to and from court related appointments, in addition to medical appointments.

 

The WC4- Request for Repayment of Unclaimed Restitution is submitted by the Clerk of the Court or Probation & Parole when the appropriate recipient of unclaimed restitution has been identified. The repayment will be returned to that office or distributed to the victim as the WC4 directs.

 

WC1 should be filled out by the Clerk of the Court when they are submitting unclaimed restitution to VVF. The fund will hold these monies until the locality notifies the Fund that the victim entitled to the restitution payment has come forward to collect the payment.

 

The WC2- Unclaimed Restitution Report is used to itemize multiple unclaimed restitution amounts. When the Clerk of the Court submits unclaimed restitution to the Virginia Victims Fund, this form provides the information necessary for the Fund to create accounts and store the monies until the victims can be found.

 

The Claim Form serves as the application to the Virginia Victims Fund. Victims indicate their interest in receiving benefits from VVF by providing this form to our office.

 

The Work Release allows a doctor to verify the time that a victim could not work due to crime related injury.