Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Page 17

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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
Section 2 - Claimant information and signature continued.
I Certify that I am the person named below (Claimant to the Victim Compensation Fund or Authorized Representative of the
Claimant) and I authorize the release of information listed above, including disclosure of information by the WTC Health
Program to the VCF, for the purposes of evaluating my claim for compensation under the VCF. I understand that the
knowing and willful request for or acquisition of a record pertaining to an individual under false pretenses is a criminal offense
subject to a $5,000 fine.
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/
Date (mm/dd/yyyy)
Signature of Claimant or Authorized Representative(s)
Print Name
Relationship to Claimant
Type of coverage to which this authorization applies (the doctor, health care provider or other entity will indicate all that apply)
Medical
Disability
Pharmacy
Long Term Care
Other. Please specify/describe.
5210579931
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Parent category: Legal