W. Va. Code R. § 64-84 app. A
STATE OF WEST VIRGINIA
DEPARTMENT OF HEALTH
OFFICE OF THE CHIEF MEDICAL EXAMINER
AGREEMENT FOR PAYMENT OF FEES FOR SERVICES INVOICE
TO: DATE: RE:
Fees authorized by law; W. Va. Code § 16-1-11, Fees for Services, 64CSR51, and Medical Examiner Requirements for Postmortem Inquiries, 64CSR84
___ Staff/M.D./PH.D. Testimony (or deposition) out of the office: $_____________
Minimum fee of $1,000 (for up to 2 hours), and $500 per each additional hour, or fraction thereof.
Other Staff: $300/hour (64CSR84, §28).*
____ Staff/M.D./Ph.D. Deposition, in office: $500 per hour, or fraction thereof (64CSR84, §28). $_____________
____ Consultation in office: $400/hour, or fraction thereof (64CSR84, §28).*
____ Use of autopsy suite: $1,000/hour or fraction thereof (64CSR84, §27).* $_____________
____ Use of OCME Office for deposition: $300/hour or fraction thereof (64CSR84, §27).* $_____________
____ Cremation Permits: $50 per case (W. Va. Code § 61-12-9 and 64CSR84, §13.8).* $_____________
____ Histology Services: microscopic slide re-cuts: $50 per slide (64CSR84, §21.8.c).$______________
____ Copying x-rays: $50/film (64CSR51, §§4.3 & 4.4). $_____________
____ Photocopying, duplication, etc.: $0.50/page (64CSR51, §§4.3 & 4.4). $_____________
____ Post-mortem Examination Reports to Family: a report of autopsy or external examination and toxicology report (64CSR84, §19.5) will be sent to authorized family member for a fee of $15, upon written request. $_____________
____ Post-mortem Examination Reports (Notarized): $300 per case (64CSR84, §19.5) $_____________
(Report of autopsy or external examination and toxicology report)
____ Photograph copying: $2.00 per photograph or $30 per CD (64CSR51, §§4.3 & 4.4).$_____________
____ Civil Request: Viewing of OCME material: $100/hour, or fraction thereof (64CSR84, §27) $_____________
____ Autopsy Wet Tissue Specimen and Body Fluid Storage: The OCME stores samples for 1 year at no cost. Longer storage beyond 1 year may be requested for a fee of $500 every 3 months, requiring a letter of request (64CSR84, §27); Requestor must submit timely written request and the additional fee payment for each quarter year of additional storage desired or the specimen(s) will be discarded. $_____________
____ Medico-legal Investigation Training Course: $$ Varies per course. Registration per attendee based on location and associated services required; $50 processing fee for regular registration cancellation; late cancellation (within two weeks of conference) - 50% of registration will be withheld; and for cancellation during or after conference - registration payment is non-refundable. $_____________
CRM/05/20/13 Total Due: $_____________
Office of the Chief Medical Examiner
619 Virginia Street, W.
Charleston, WV 25302
Phone (304) 558-6920 FAX (304) 558-8492
Authorization:
The Office of the Chief Medical Examiner has established fees for a number of services provided by this Office in accordance with our authority under W. Va. Code § 16-1-11 and § 61-12-3et seq. as well as two Bureau for Public Health legislative rules: Medical Examiner Requirements for Postmortem Inquiries, 64CSR84, and Fees for Services, 64CSR51. The service(s) you have requested are subject to these fees.
Payment:
Please do not send cash. Please make check payable to the Office of the Chief Medical Examiner and mail to 619 Virginia Street, W., Charleston, W. VA. 25302. Please record the name of the decedent on your check. Please note that the OCME reserves the right to require expected fee payment prior to performing requested services. Cancellations should be made within 48 hours or the fee will be non-refundable.
Payment must be received before services will be rendered (excluding * services).
Rendered Services:
For services rendered before payment is received the below authorization must be signed:
I hereby agree to pay the Office of the Chief Medical Examiner as invoiced for the above-
mentioned service. Invoice to be prepared upon completion of services.
Authorized Signature: _____________________________________________________
Title of Person Signing: ___________________________________________________
Date: _________________________________________________________________
Office of the Chief Medical Examiner
619 Virginia Street, W.
Charleston, W. VA. 25302
Phone (304) 558-6920 FAX (304) 558-8492
W. Va. Code R. 64-84 app A