| Activity Prescription Form to Treat Crime Victims |  | |
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Insurer Activity Prescription Form (APF)
About the APF
Effective August 1, 2009.
Why is the Crime Victims Compensation Program (CVCP) releasing this new form?
To reduce providers' paperwork:
- By reducing the number of requests for information about CVCP clients.
- By providing integrated medical/mental health information on victims' conditions, restrictions, and prognoses.
- There will be a transition period.
| Transition period | |
|---|---|
| During the transition period for dates of service of August 1, 2009 through October 31, 2009: | CVCP will pay health care providers for any of the forms which are being replaced. |
| After the transition period (starting November 1, 2009): | Providers will be required to submit an APF upon request from the CVCP claims manager. To receive payment the form must be completed in full. Bill code 1074M for this service. |
By replacing multiple forms with 1 using the following schedule:
- Time Loss Notification - Recycle after August 1, 2009.
Note: Victim verification forms (VVFs) will be sent to the victims who may be eligible to receive time-loss compensation. Only the victim signs this form. If necessary, your signature on APFs will also certify time-loss compensation. - Supplemental Medical Report - Recycle after August 1, 2009.
- Physician Final Report (not a form) - Recycle after August 1, 2009.
The APF communicates:
- Work status.
- Crime-related physical or mental health restrictions.
- Verification of time-loss (if appropriate)
- Treatment plans.
Call CVCP at 1-800-762-3716 for more information.
