Office of Crime Victim Services

SEXUAL ASSAULT FORENSIC EXAM FUND (SAFE FUND)

Please Note: The Crime Victim Compensation Program may be able to provide more assistance than the SAFE Fund.  Individuals can apply for assistance through the Crime Victim Compensation Program if the crime is reported to law enforcement and they intend to cooperate through prosecution.

However, if a victim does not wish to report the crime to law enforcement or, for reasons of confidentiality, does not wish to report the crime to his or her insurance provider; the SAFE Fund can provide limited financial assistance:

• The Fund may be able to pay for the Sexual Assault Forensic Exam for those mentioned above. Medications other than Plan B may be reimbursed if directly related to the assault.
  
• There is no application, but the request for payment form below must accompany each bill.
  
• The individual wishing to receive assistance from the SAFE Fund must contact the billing department at the hospital, inform them that they wish to have the forensic exam paid by the SAFE Fund, and the hospital can then submit the itemized bills to the Fund, along with the completed request for payment form.
  
• If the victim is not sure, at the time of service, whether they will seek assistance from the SAFE Fund (and/or whether they will make a claim to his or her insurance agency, etc.) the hospital staff should ask the victim to contact the hospital with that decision so the hospital will know if bills should be sent to the SAFE Fund.

Questions can be directed to Kathy Zupan, Director, Crime Victim Compensation Program at 264-9484 or 1-800-446-6564.

REQUEST FOR PAYMENT FROM DEPARTMENT OF JUSTICE FORM

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