State of Nevada
Victims of Crime Program
Request for Pre-Authorization for Payment
Submit this form when requesting pre-authorization for payment for services to victim for any crime related expense
Victim/Patient Name: VOCP Claim #
Service or Treatment Information:
Description of service or treatment: (include CPT and HCPCS codes) Attach Billing Documents.
What is the cost or estimated cost of this service or treatment?
Is this service or treatment necessitated by the crime? Yes? No?
If No please explain:
Is any portion of this covered by Insurance, or did the Applicant/Victim pay any portion of this claim?
If Yes please explain:
The information provided herein is true and accurate to the best of my information and belief.
Authorized Signature: Print Signers Name: Date:
Tele: Fax: Email:
Mail to: VOCP
6171 W. Charleston Blvd., Bldg. 9
Las Vegas, NV 89146
Scan and email to:
VOCP Pre-Authorization for Payment for Treatment or Services:
This Authorization is only valid for 60 days after date approved by the Compensation Officer
Amount Approved $ Date CCSI Review:
Compensation Officer Signature (Required for