SAFE Request for Payment Form

Download SAFE Request for Payment Form

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 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 medical provider who performed the forensic medical exam should complete this form.

The completed form may be returned by WebFile or U.S. Mail.

  • For fastest and most efficient turnaround, please use WebFile to submit this form.
    The Forensic Nurse Examiner (FNE) WebFile Portal is the Virginia Victims Fund’s online portal system designed for SAFE claims. The FNE WebFile Portal is intended for forensic nurses to file SAFE claims, submit claim documentation and check the status of claims.
  • U.S. Mail:
    Virginia Victims Fund, P.O. Box 26927, Richmond, VA 23261