Treating Physician Information Form/authorization For Release Of Medical Records Form - September 11th Victim Compensation Fund - Page 7

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Treating Physician Information Form
Treating Physician Contact Information
** 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:
_____________________________________________
Physician Address:
_____________________________________________
City__________________State____ Zip____________
Physician Phone:
(_______)_____________________________________
Physician Fax:
( _______)____________________________________
Physician Email:
_____________________________________________
Please also provide the state(s) where the physician is licensed to practice medicine,
the corresponding license number(s) and any practice specialties along with the
corresponding AMA Physician Specialty Code.
State(s) and license number(s):
________________________________________________________________
________________________________________________________________
Specialties and AMA Physician Specialty Codes:
________________________________________________________________
________________________________________________________________
________________________________________________________________
Page 2
P.O. Box 34500, Washington, D.C. 20043

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