(1) To be eligible for reimbursement for the covered costs of the forensic rape examination, the medical provider must, within 90 days of performing the examination:

(a) submit the FREPP claim form;

(b) provide a copy of the patient information form;

(c) provide an itemized statement of charges listing current procedural terminology (CPT) codes on a standard health care financing administration (HCFA) form; and

(d) provide copies of all pertinent treatment records.

(2) All billing paperwork should be mailed to the Office of Victim Services, ATTN: FREPP, P.O. Box 201410, 1712 9th Ave., Helena, MT 59620-1410.