Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Page 3

Download a blank fillable Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

** This form should be completed by the Claimant **
Assessing Exposure to the September 11, 2001 Attacks –
Pentagon or Shanksville, Pennsylvania
Complete this form if you were present at the Pentagon or Shanksville, PA sites. If you were present
at the New York City Disaster Area, please use the version of the form specific to that site.
For the purposes of completing this form, please use the following definitions:
-
A Responder is a worker or volunteer who provided rescue, recovery, demolition, debris
removal, and related support services in the aftermath of the September 11, 2001 attacks on
the Pentagon or the Shanksville, Pennsylvania site.
A Non-Responder is a person who was present at the Pentagon in the aftermath of the
-
September 11, 2001, terrorist attacks as a result of their work, residence, or attendance at
school, childcare, or adult daycare.
If the Claimant was a Responder to the Pentagon or Shanksville, Pennsylvania site, complete the
form starting on this page.
If the Claimant was a Non-Responder at the Pentagon, complete the form starting on page 3.
* * * * * * * * * * * * * * * * * * * *
Claimant’s Name:
VCF Claim Number: VCF__________
1. Indicate the site where the Claimant was located:
Pentagon
Shanksville, Pennsylvania
Specify Location:
2. Dates of response and recovery service (MM/DD/YYYY):
Start:
Finish:
Comments (optional):
3. Average hours per day:
_________________________
4. Estimate of total time engaged in response and recovery work:
_____Days
Weeks
Months
Comments (optional):
Page 1
P.O. Box 34500, Washington, D.C. 20043

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal