Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Page 6

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Treating Physician Information Form
Treating Physician Information Form
** This form may be completed by the Physician or the Claimant **
Please complete a separate version of this form for each treating physician.
Claimant Name:
_____________________________________________
VCF Claim Number:
VCF __ __ __ __ __ __ __
Physician Name:
_____________________________________________
In the below chart, list the conditions for which the claimant is currently being (or previously
was) treated by the physician. For each condition, provide the earliest date (month and year) of
symptom onset and the date of first diagnosis (month and year).
Please provide copies of relevant records to support the diagnoses for the conditions listed
below and any other information that might be relevant to the VCF, such as the effect of the
condition(s) on the claimant. Please refer to the “Diagnostic Essentials: Physical Health
Conditions” document for the type of information that is required in order to verify a
condition for compensation from the VCF.
If applicable, please also provide a summary of any complications of treatment (i.e., new
diagnoses stemming from treatment) and provide applicable medical records.
Earliest Date of
Date of First
Condition Treated
Symptom Onset
Diagnosis
(month/year)
(month/year)
Page 1
P.O. Box 34500, Washington, D.C. 20043

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