N.H. Code Admin. R. Jus 604.06
Verification of Medical Expenses Form
Effective Dec 9, 2019#4864, eff 7-13-90, EXPIRED: 7-13-96 New. #7117, eff 10-8-99, EXPIRED: 10-8-07 New. #9553, eff 9-25-09, EXPIRED: 9-25-17 New. #12938, eff 12-9-19 (formerly Jus 604.07)Attorney General, Department of Justice
- (a) If a claimant seeks compensation for medical expenses, the victim or victim’s parent or guardian shall complete and submit a HIPAA- compliant hospital and/or medical release. Upon receipt of the HIPAA- compliant release form the unit shall request that each provider complete and submit a “Verification of Medical Expenses Form,” as revised 8/23/2019.
- (b) In addition to the form, the provider shall submit an itemized statement and medical records relating to injuries directly resulting from the crime.
Source. #4864, eff 7-13-90, EXPIRED: 7-13-96 New. #7117, eff 10-8-99, EXPIRED: 10-8-07 New. #9553, eff 9-25-09, EXPIRED: 9-25-17 New. #12938, eff 12-9-19 (formerly Jus 604.07)