OMB 1105-0092
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Claimant's SSN or National ID Number
September 11th Victim Compensation Fund
September 11th Victim Compensation Fund
Exhibit A to the Eligibility Form For Personal Injury Claimants
Exhibit A to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Medical Records
Authorization for Release of Medical Records
providers and/or the VCF may also disclose this information to the WTC Health Program for the purpose of
evaluating your claim for benefits under the VCF. In addition, the WTC Health Program may disclose
information to the VCF for purposes of evaluating your VCF claim. This information includes, but is not limited
to, whether you are a member of the WTC Health Program, and if so, where you receive your WTC Health
Program health care benefits; whether you have been certified for treatment under the WTC Health Program;
the number of and specific conditions for which you have been certified for treatment under the WTC Health
Program; and information relating to payment of claims for treatment and pharmaceuticals received under the
WTC Health Program.
Disclosure requested will include otherwise confidential information. If records include claims or
other information pertaining to chronic diseases, behavioral health conditions, including alcohol or
substance abuse, communicable diseases, including HIV/AIDS, and/or genetic marker information, these
records will be included in the information made available to the VCF.
I understand that this authorization is voluntary. However, if you refuse to sign this authorization, the
VCF will not be able to process your claim for compensation.
By initialing, I acknowledge that the information described above may include mental health
Initial here:
information and I authorize the release of such information.
I hereby authorize the person, carrier or other entity listed below to disclose confidential information about the
claimant listed below to the VCF, the DOJ and NIOSH:
Section 1 - Name, telephone number and email address for doctors, health care providers or other entities.
Physician/Other Entity or Program:
Doctor/Provider/Entity Name
Doctor/Provider/Entity Address
Doctor/Provider/Entity Address continued
Suite Number
City
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State/Province
Zip/Postal Code
Telephone Number
Email Address
3791579933
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