If the victim/applicant is requesting the Bureau of Victim Compensation to consider payment of any expenses, they are to provide their claim number to the service provider and request that an itemized bill be sent to the department. The victim/applicant may also submit the expense themselves if payment was made out-of-pocket.

The itemized bill (invoice) should be prepared using industry standard forms (e.g., CMS-1450, 1500, J400), or on the provider’s letterhead and must include the following information:

1. Service provider/facility’s name, street address, city, state and zip code, email address, and telephone number (including area code);
2. Organization/treatment facility’s mailing address;
3. Federal tax identification number;
4. Beginning and ending date(s) of service;
5. Name and address of individual being billed for services rendered;
6. Revenue code, description of service, CPT or equivalent code, service date, service units, and total charges;
7. Diagnosis code, diagnosis, or nature of injury; and
8. First and last name of attending medical professional and license number.

Expenses for eligible claims should be submitted via email to VCIntake@MyFloridaLegal.com, or by fax to (850) 414-6197. To ensure expenses are forwarded to the applicable claim, the claim number should be documented at the top of the bill. Approved VANweb portal users may also submit bills electronically on existing claims.