Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund -

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Instructions to Claimants:
Information from Private Physicians
Instructions to Claimants – Pentagon and Shanksville, PA Disaster Areas
Gathering and Submitting Information from Private Physicians
The September 11th Victim Compensation Fund (“VCF”) works closely with the World Trade Center
(“WTC”) Health Program to determine whether a claimant’s medical condition(s) can be certified as
eligible for compensation from the VCF. For claimants who are being treated by private physicians
outside of the WTC Health Program, the VCF gathers the claimant’s medical and exposure information
and submits it to the WTC Health Program for review. Without information from the WTC Health
program or a claimant’s treating physician, the VCF cannot deem a claimant eligible for
compensation. Please follow the instructions below and use the enclosed documents to gather the
information the VCF needs in order to verify the claimed condition is eligible for compensation.
Step 1: Review the enclosed documents to understand the type of information that is needed. The
documents can also be found on the website under “Forms and Resources”. The
website also has Frequently Asked Questions (“FAQs”) about the Private Physician process.
Step 2: Review in detail the “Assessing Exposure to the September 11
, 2001 Attacks Form” and
complete the form, being careful to use either the Responder or Non-Responder version based
on the claimant’s specific circumstances.
Step 3: Review the WTC Health Program “Diagnostic Essentials: Physical Health Conditions”
document. The guidelines outline the specific documentation that is required in order to
verify a condition for compensation from the VCF. Review the required documents for the
specific injury being claimed to confirm you will be able to provide the requested information.
Step 4: Complete the 2-page “Treating Physician Information Form” using a separate form for each
treating physician. This form can be completed by the claimant or the physician. Please list the
conditions for which the claimant is being treated and the year of earliest diagnosis/symptom
and provide relevant medical records (as outlined in the “Diagnostic Essentials” document) that
support the diagnosis. If the claimant completes the form, please notify the physician that the
form has been submitted to the VCF.
Step 5: Complete an “Authorization for Release of Medical Records Form” for each physician whose
information is included in a “Treating Physician Information Form”. Provide one original version
of the Authorization Form to the individual physician and send a second original version to the
VCF. It is important that you complete one Authorization for each physician and provide the
completed, original Authorization forms to both the VCF and your physician(s). The
Authorization Form authorizes the physician(s) to speak with the VCF about the claimant’s
treatment. Please note there is one version of the form for Personal Injury claimants and one
version for those filing a claim on behalf of a Deceased Individual.
Step 6: Gather the completed forms and relevant records from each physician and write the claimant’s
name and VCF claim number on the first page of each form or document. Finally, complete the
“Cover Sheet for Return of Completed Private Physician Forms” and upload the cover sheet
and documents to the online claim or mail them in a single package to the VCF at:
For overnight deliveries:
September 11th Victim Compensation Fund
September 11
Victim Compensation Fund
PO Box 34500
1220 L Street NW
Washington, DC 20043
Suite 100 - Box 408
Washington, DC 20005-4018
When uploading the forms to your online claim, please select “Private Physician Forms” from
the list of document types. Please do not upload or mail the documents separately. It will
speed processing if all of the documents for a single claim are uploaded at the same time or
sent as one package to the VCF.
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P.O. Box 34500, Washington, D.C. 20043


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