SAFE Program Guidelines

The victim or the victim’s guardian shall consent in writing to the examination.

The medical provider shall not charge the victim for the forensic examination.

For billing purposes, claims shall not include charges for the medical treatment. Medical treatment means the treatment of all injuries and health concerns relating directly from a patient’s sexual assault or victimization including, but not limited to the following:

1. Testing for sexually transmitted diseases (STD) or human immunodeficiency virus (HIV) unless victim is under fourteen (14) years of age;
2. Treatment/prophylaxis of STD or HIV;
3. Any antibiotic prophylaxis;
4. Pregnancy testing;
5. Emergency contraception;
6. Tetanus immunization;
7. Wound care, laceration repair;
8. Fractures/sprain treatment;
9. Surgical procedures;
10. Discharge instruction counseling; and
11. Outpatient follow-up.

All claims for sexual assault forensic examination charges must be submitted to the department within ninety (90) days from the date of the forensic examination.

The Department, at its discretion, may require proof of completion of forensic examinations for auditing purposes.

To file a claim for the payment of the sexual assault forensic examination charges, the medical provider must submit the following documentation:

1. Sexual Assault Forensic Examination Program Report;
2. Sexual Assault Forensic Examination Checklist; and
3. An itemized bill.

The appropriate forms and itemized bill should be mailed to: