Cover Sheet for Return of
Completed Private Physician Forms
Cover Sheet for Return of Completed Private Physician Forms, Associated Records,
and Assessing Exposure Worksheets
Claimant Name: _____________________________________________
Claim Number: VCF __ __ __ __ __ __ __
Please complete this form and include it with the Private Physician forms and relevant documents that are
uploaded to the online claim or mailed to the VCF. This form notifies the VCF that all of the applicable
documents have been received for the claim. For claimants who have one or more physicians who will mail
the information directly to the VCF, this form identifies the physician(s) and notifies the VCF that the
documents will be submitted.
When uploading the forms to your online claim, please select “Private Physician Forms” from the list
of document types. This will help ensure your forms are properly categorized for faster processing. Please
see FAQ #4.12 on the ww.vcf.gov website for step-by-step instructions for uploading documents to your
claim.
** Claimants should submit the completed forms and relevant records in ONE package
or upload the documents to the claim at the same time unless the physician is
mailing the information directly to the VCF. **
Check here if this package includes all information and documents the claimant expects to
submit to the VCF regarding treatment by physicians outside of the WTC Health Program.
Check here if this package includes all physician information and documents being
submitted by the claimant, but additional documents will be mailed directly to the VCF by the
physician(s). If selecting this option, please indicate in the spaces below the names of the
physicians who will mail documents to the VCF.
Check here if all information and documents will be sent to the VCF directly by the
physicians (claimant will not submit any additional forms beyond those submitted by
physicians). If selecting this option, please indicate in the spaces below the names of the
physicians who will mail forms to the VCF.
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P.O. Box 34500, Washington, D.C. 20043
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