Vermont Payment Resources
Summary of payment program
Vermont Health Providers Documents – Sexual Assault Billing Form
A victim of sexual assault will go to an Emergency Room to access services. That person will be seen by a specially trained Sexual Assault Nurse Examiner (SANE). The SANE nurse explains the examination process to the victim and will ask the victim to fill out and sign a Sexual Assault Billing Form. The signed Sexual Assault Billing Form gives the Center for Crime Victim Services permission to:
- pay the victim’s bill
- contact the medical provider or victim’s insurer to obtain initial sexual assault bills
- access follow-up bills
- obtain an explanation of benefits from a victim’s insurance company.
This documentation is needed in order for the Program to pay for the sexual assault bills. The Sexual Assault Program covers eligible sexual assault charges when a victim is uninsured or has an out of state insurance policy.
The Sexual Assault Program (SAP) offers services to victims. The victim does not need to report the crime to law enforcement to receive these services. The Sexual Assault Program offers victims trained Sexual Assault Nurse Examiners at hospitals in Vermont, testing, treatment, support services, HIV infection prevention and a limited amount of counseling.
The Sexual Assault Program through the Center for Crime Victim Services provides resources for payment of out of pocket medical expenses after a victim’s insurance has been billed for sexual assault examinations following the crime.
Resources are available to pay for the initial sexual assault medical examination to include:
- collection of evidence
- STI (sexually transmitted infections) and HIV screening
- pregnancy testing
- treatment of related injuries
The Program also pays for certain medical follow-up care related to the sexual assault. The Program can also consider payment of up to 20 sessions of mental health counseling with a licensed mental health provider of your choice for treatment related to the sexual assault.
The Vermont Victims Compensation Program provides limited financial assistance to victims of crime. The financial loss has to be the direct result of the crime, and is not reimbursable through other sources, such as insurance.
The Vermont Victims Compensation Program is established in state statute, which can be found at 13 V.S.A. § Chapter 167. Other statutes that relate to the Victims Compensation Program are the Public Records Law 1 V.S.A. § 317(c)(41) and the Restitution statute found at 13 V.S.A. § 7043 (c)(2) and (3).
▪ The crime has been reported to a law enforcement officer, who must conclude that a crime was
▪ The victim has suffered physical injury or emotional harm as a direct result of a crime.
▪ The crime was committed in Vermont, or was committed against a Vermont resident in a country that
does not have a Compensation Program.
▪ The crime was committed after July 1, 1987.
▪ The victim did not violate a criminal law of this state which caused or contributed to his or her injuries or
▪ Family members of a homicide victim are also eligible.
Complete all of areas of the application. When filling out the application make sure:
1. The application is signed and dated after the “certification statement.”
2. To sign and date the “Authorization to Obtain Information” section of the application. Provide an
alternative expiration date if desired.
3. To sign and date the “Repayment, Restitution, and Subrogation” section of the application.
4. After application is filled out, tape or staple all sides to seal before mailing.
Prefer to mail the application to VCP in a separate envelope and do not have a stamp, contact the Victims Compensation Program and they will send the applicant a postage paid envelope to mail their application and/or bills.
Victims Compensation Program
58 South Main Street, Suite One
Waterbury, Vermont 05676-1599
1-800-750-1213 (Voice – VT only)
Coordination with healthcare
Vermont Network Against Domestic & Sexual Violence – Find help in Vermont