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CVCP Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.

Crime Victims Compensation Opioid Progress Report Chronic, Non-Cancer Pain and Treatment Agreement.



Formulario
F800-116-000
 
Help for Victims of Crime / 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.

Pamfleto/folleto: Responde preguntas sobre el Programa de Compensación para Víctimas de Crimen del estado de  Washington, quienes podrían tener derecho a recibir beneficios y cómo pueden aplicar. 

 



Publicación
F800-006-909
 
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.



Formulario
F800-031-000

Otro(s) idioma(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.



Formulario
F800-042-000

Otro(s) idioma(s):
Español
 
Application for Benefits- Crime Victims Spanish - Instrucciones para: Solicitud para Beneficios para Víctimas de Crimen

Instrucciones en español para completar el formulario F800-042-000, Solicitud para beneficios para víctimas de crimen.  El formulario es utilizado por víctimas de crimen en el estado de Washington para recibir beneficios de tiempo perdido del trabajo, pérdida de apoyo económico, tratamiento médico y de salud mental.  Esta versión del 10 de diciembre está en Internet solamente.



Formulario
F800-042-999

Otro(s) idioma(s):
Inglés
 
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.



Formulario
F800-057-909
 
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.



Formulario
F800-058-000
 
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.



Formulario
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.



Formulario
F800-065-000
 
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.



Formulario
F800-070-000
 
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.



Formulario
F800-076-000
 
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)



Formulario
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.



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

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



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

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



Formulario
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.



Formulario
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.



Formulario
F800-089-000
 
Help for Crime Victims (large poster)

Poster (11" X 17"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice and social-service organizations. Can be downloaded and printed, or ordered from L&I. Smaller version is also available (8.5" X 11"). Get 11" X 17" poster printing tips.



Cartel
F800-041-000

Otro(s) idioma(s):
Español
 
Ayuda para Víctimas de Crimen (cartel grande)

Cartel (11" X 17"): Resalta el Programa de Compensación para Víctimas de Crimen y proporciona información para comunicarse con el programa. La intención es ponerlo a la vista en clínicas, organizaciones judiciales y de servicios sociales. Puede descargarse e imprirse o solicitarse de L&I.  Hay una versión más pequeña (8.5" X 11") disponible.



Cartel
F800-041-999

Otro(s) idioma(s):
Inglés
 
Application to Reopen Claim - Spanish Aplicación para Reabrir un Reclamo Debido al Empeoramiento de la Condición

Los beneficios están limitados a $50,000 por reclamo. Si su reclamo ha llegado o excedido  este límite, su solicitud de reapertura será negada y no podremos pagar beneficios futuros.  Usado por las víctimas de crimen y proveedores médicos o de salud mental para solicitar la reapertura de un reclamo.



Formulario
F800-031-999

Otro(s) idioma(s):
Inglés
 
Help for Crime Victims (small poster)

Poster (8.5" X 11"): Highlights the Crime Victims Compensation Program and provides contact information. Intended for display in health-care, criminal-justice, and social-service organizations. Can be downloaded and printed, or ordered from L&I. Larger version is also available (11" X 17").



Cartel
F800-104-000

Otro(s) idioma(s):
Español
 
Ayuda para Víctimas de Crimen (cartel)

Cartel (8.5" X 11"): Resalta el Programa de Compensación para Víctimas de Crimen y proporciona información para comunicarse con el programa. La intención es ponerlo a la vista en clínicas, organizaciones judiciales y de servicios sociales.  Puede descargarse e imprirse o solicitarse de L&I. Hay una versión más grande (11" X 17") disponible.



Cartel
F800-104-999

Otro(s) idioma(s):
Inglés
 
Statement for Crime Victims Mental Health Services

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



Formulario
F800-025-000
 
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
 
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
 





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