Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Page 5

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** This form should be completed by the Claimant **
Please begin here if the Claimant was a Non-Responder at the Pentagon.
Claimant’s Name:
VCF Claim Number: VCF__________
1. Immediately following the September 11, 2001 terrorist attack, where was the Claimant
located?
2. How long was the Claimant located at the site?
3. Describe circumstances surrounding the Claimant’s presence at the site:
4. Optional – Please use this space to provide additional comments for consideration
** End of Non-Responder – Pentagon Form **
Page 3
P.O. Box 34500, Washington, D.C. 20043

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