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Claimant's SSN or Nat'l ID #
OMB 1123-0012
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SEPTEMBER 11TH VICTIM COMPENSATION FUND
ELIGIBILITY FORM FOR PERSONAL INJURY CLAIMANTS
Eligibility Form
(Parts I- IV)
PART I. CLAIMANT AND CLAIM INFORMATION
A.
GENERAL CLAIMANT INFORMATION
Claimant's Last Name
First Name
Middle Name
Mailing Address
Mailing Address
Apartment/Suite Number
City
State/Province
Zip/Postal Code
Country
Email Address
/
/
(
Date of Birth (mm/dd/yyyy)
(
)
)
-
Telephone Number (Home)
-
(
Telephone Number (Work)
)
-
Telephone Number (Mobile)
-
-
Country of Citizenship
Social Security or National ID Number
Passport Country (if not U.S.)
Passport Number (if not U.S. and available)
Please indicate if you would like correspondence to be provided via e-mail. Please note, selecting this
option will require you to register at www.VCF.gov.
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Claimant's SSN or Nat'l ID #
OMB 1123-0012
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B. INFORMATION ABOUT THE CLAIMANT'S GUARDIAN OR OTHER AUTHORIZED
REPRESENTATIVE (IF APPLICABLE)
Please complete this Section B only if the Claimant has a guardian or someone other than the injured Claimant is
submitting this form. (Note: If represented by an attorney, attorney information should be provided in Section C,
not in this Section B).
Representative’s Last Name
First Name
Middle Name
Mailing Address
Mailing Address
Apartment/Suite Number
City
Zip/Postal Code
Country
State/Province
Email Address
(
)
-
(
Telephone Number (Home)
(
)
)
-
Telephone Number (Work)
-
Telephone Number (Mobile)
-
-
Country of Citizenship
Social Security or National ID Number
Passport Country (if not U.S.)
Passport Number (if not U.S. and if available)
1303300527
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Claimant's SSN or Nat'l ID #
OMB 1123-0012
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B. INFORMATION ABOUT THE CLAIMANT'S GUARDIAN OR OTHER AUTHORIZED
REPRESENTATIVE (IF APPLICABLE) (continued)
Representative's relationship to the Claimant:
Parent of minor
Indicate here if you have sole legal custody of the minor
Indicate here if you have joint legal custody of the minor
Note: If you share or have joint custody of the Claimant with someone else,
both signatures are required wherever this claim form asks for a signature.
If you have joint legal custody of the minor, please complete the joint custody
information section below for the person with whom you share custody:
Last Name
First Name
Middle Name
Mailing Address
Mailing Address
Apartment/Suite Number
City
State/Province
Zip/Postal Code
Country
Email Address
(
)
-
(
Telephone Number (Home)
(
)
)
-
Telephone Number (Work)
-
-
Telephone Number (Mobile)
Social Security or National ID Number
Country of Citizenship
Passport Country (if not U.S.)
-
Guardian of minor
Passport Number (if not U.S. and available)
Guardian of non-minor
Representative of deceased individual who is alleged to have suffered physical harm covered by the
Zadroga Act but whose death is not claimed to have resulted from those crashes or debris removal efforts.
See Instructions for important additional information that must be provided with this claim.
Other
Explanation
Please note: The authorized representative must submit proof of his/her authority to act on behalf of the
Claimant in order for the VCF to process the claim. See Instructions and Supporting Document Checklist at
the end of this form.
2159069710
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
C. INFORMATION ABOUT THE CLAIMANT'S ATTORNEY OR ALTERNATE CONTACT PERSON
(IF APPLICABLE)
If an attorney or other authorized individual is assisting the Claimant with this claim, please indicate and fill out the
information below:
Attorney
Title:
Other Individual
Relationship to Claimant:
Last Name
First Name
Middle Name
Law Firm or Organization
Mailing Address
Mailing Address
Apartment/Suite Number
City
Zip/Postal Code
Country
State/Province
Email Address
(
)
-
Telephone Number
The Claimant should indicate here and complete the certification at Part IV.F (Authorization of
Attorney Communication and Correspondence) if the Claimant authorizes the VCF to communicate
with this individual about his/her claim. The Claimant may also indicate at Part IV.F if he/she would
like to receive a copy of all VCF written correspondence regarding his/her claim.
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Claimant's SSN or Nat'l ID #
OMB 1123-0012
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D. INFORMATION ABOUT THE CLAIMANT'S PRIOR CLAIM WITH THE SEPTEMBER 11TH VICTIM
COMPENSATION FUND (IF APPLICABLE)
Was a claim previously filed by or on behalf of the Claimant with the original September 11th Victim
Yes
No
Compensation Fund of 2001?
If no, please proceed to Part I.E.
If yes,
What injury/injuries did the Claimant allege in connection with the prior claim?
Please Specify
Yes
Was a payment issued on the claim?
No
If no, was the claim denied/determined to be ineligible?
Do not know
Yes
No
If yes, what was the basis for the ineligibility determination?
Outside the original Victim Compensation Fund zone
Did not sustain physical harm
Did not sustain physical harm within requisite timeframe
Other reason for ineligibility
Please Specify
Do not know
If yes,
For what injury/injuries was the Claimant previously compensated?
Traumatic Injury
Please Specify
Respiratory or other latent injury
Please Specify
Other
Do not know
Yes
Was the Claimant compensated for any disability or future lost wages?
Permanent disability
Temporary disability
If yes, was it for a:
No
Do not know
Which of the following categories describes the Claimant's current circumstances?
(Select any that apply)
The Claimant now suffers from an injury that the
Claimant had not suffered at the time the Claimant filed
the previous claim with the Victim Compensation Fund
The Claimant suffers from an injury that the Claimant
did not reasonably know of at the time that the Claimant
filed the previous claim with the Victim Compensation
Fund
The Claimant suffers from a condition that the Special
Master has identified as a presumptively covered
condition since the time the Claimant filed the previous
claim with the Victim Compensation Fund
The Claimant is claiming the same injury for which the
previous Victim Compensation Fund claim was filed but
that injury has substantially worsened, resulting in
damages or loss that was not previously compensated.
The Claimant's presence at a 9/11 crash site fell
outside the eligibility requirements of the original
September 11th Victim Compensation Fund of 2001 but
now satisfies the requirements based on amendments
contained in Title II of the Zadroga Act (e.g., the
Claimant was present outside of zone of danger defined
by the original Victim Compensation Fund).
Other/Do not know Please explain
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Explanation
Explanation
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Claimant's SSN or Nat'l ID #
OMB 1123-0012
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E. INFORMATION ABOUT THE CLAIMANT'S PARTICIPATION IN LAWSUITS RELATED
TO SEPTEMBER 11, 2001 (IF APPLICABLE)
1. Has the Claimant or any dependent, spouse or beneficiary of the Claimant filed a lawsuit or been a party to a
lawsuit in any court for damages as a result of the September 11, 2001 attacks (including damages related to
debris removal)? (Note: Do not include in this section any lawsuit to recover collateral source obligations (such as
insurance or Social Security) or a lawsuit against any person who is a knowing participant in any conspiracy to
hijack or commit any terrorist act.)
Yes
No
If no, please proceed to Part I.E 2 below
If yes,
Was the lawsuit commenced after December 22, 2003?
Yes
No
Has the lawsuit been dismissed or withdrawn?
Yes
No
/
If yes, when was the lawsuit dismissed or withdrawn?
Has the lawsuit been settled?
If yes,
Yes
Date(mm/dd/yyyy)
No
Yes
Did the individual settle all claims?
If yes,
/
No
,
What was the total settlement amount?
What injuries or damages were claimed in the lawsuit? Please specify
If no, have all unsettled claims been dismissed or withdrawn?
Was a release of all claims in such lawsuit tendered (i.e., signed and
submitted) prior to January 2, 2011?
,
Yes
No
Yes
No
If yes,
Who tendered (i.e., signed and submitted) the release?
Individual Claimant
Claimant’s attorney
Did the Claimant's attorney have authority to sign the
(See instructions for
release on the Claimant's behalf?
Yes
No further information.)
2. Has the Claimant filed or has any dependent, spouse or beneficiary of the Claimant filed on the Claimant's behalf
any other lawsuit or claim with any court or bankruptcy trust for any respiratory injury or disease due to exposure
unrelated to September 11, 2001? (An example would be a lawsuit for injuries related to exposure to asbestos.)
If no, please proceed to Part II
If yes,
Please provide information on any lawsuit or claim (complete for each lawsuit or claim)
Court/Trust:
Year Filed:
Docket number:
Injury/disease claimed:
Do not know:
Has the lawsuit or claim been completely resolved?
Yes
No
If yes, please provide documentation of the judgment, settlement or trust compensation
Yes
No
If no, has the lawsuit or claim been resolved in part?
5405517546
If yes, please provide documentation of the judgment, settlement or trust compensation
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
PART II. INFORMATION ABOUT THE CLAIMANT'S PRESENCE AT A 9/11 CRASH
SITE BETWEEN SEPTEMBER 11, 2001 AND MAY 30, 2002
In this Part, please identify the circumstances and locations (Section A) and corresponding time and duration
(Section B) of Claimant's presence at a 9/11 crash site from September 11, 2001 through May 30, 2002
Note: If the Claimant’s presence at a 9/11 crash site from
September 11, 2001 through May 30, 2002 involved more than
one location (for example, if Claimant was a Responder at the
WTC and also resided in the NYC Exposure Zone, or if
Claimant worked at two different buildings within the NYC
Exposure Zone), please make copies of this Part II and
complete Part II for each location.
What is the definition of a “Responder” for purposes of
this claim form?
A “Responder” is defined as an individual who performed
rescue, recovery, demolition, debris cleanup or other related
services in the NYC Exposure Zone (defined below), at the
Pentagon site or at the Shanksville, PA site in response to the
September 11, 2001 terrorist attacks, regardless of whether
the individual was a state or federal employee or member of
the National Guard or performed the services in some other
capacity. Therefore, you may be considered a Responder
even if you performed the listed services through a private
employer or on a volunteer basis.
What is the “NYC Exposure Zone” for purposes of this
claim form?
For purposes of this claim form, the NYC Exposure Zone is
defined to include:
the area in Manhattan south of the line that runs along
Canal Street from the Hudson River to the intersection of
Canal Street and East Broadway, north on East Broadway
to Clinton Street, and east on Clinton Street to the East
River; and
any area related to or along the routes of debris removal,
such as barges and Fresh Kills landfill.
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site
1. If the Claimant was a Responder within the NYC Exposure Zone
Please indicate the organization(s) for which the Claimant worked as a Responder from the list below.
Fire Department of New York (FDNY) (includes fire and emergency personnel, active or retired)
Police Department of New York City (NYPD) (active or retired)
Port Authority of New York and New Jersey Police (active or retired)
Office of the Chief of the Medical Examiner of New York City
Port Authority Trans-Hudson Corporation (PATH)
New York City morgue
Please Specify
New York State Law Enforcement (State Troopers)
New York State Department of Environmental Services
Other New York State agency Please Specify
MTA, Transit Authority
New York City Department of Sanitation
New York City Department of Design and Construction (DDC)
Other New York City agency Please Specify
Federal Law Enforcement (FBI, etc)
US Corps of Engineers
US Corps of Engineers Contractor (EE&G)
US Corps of Engineers Contractor Phillips and Jordan
U.S. Coast Guard
National Guard
Secret Service
US Environmental Protection Agency
FEMA
Other Federal Agency Please Specify
Volunteer Organization (including Red Cross and Salvation Army).
Please Specify
Volunteer (non-affiliated)
Please Specify
Union member
Please specify union and local
Utility Company (phone/gas/cable/water/electric)
Construction Company (Steel worker, engineer, transport, debris removal, grappler & excavator, demolition, etc.).
Please Specify
Barge operating company Please Specify
Trucking company
Please Specify
Trash removal company Please Specify
Maintenance company
Please Specify
Dust control company
Please Specify
Pest control company
Please Specify
Clergy
Please Specify
Other
Please Specify
5705162578
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
Please identify the Claimant's locations within the NYC Exposure Zone during the period beginning
September 11, 2001 through May 30, 2002.
On or adjacent to the pile/in the pit
Note: The "pile" or "pit" refers to the mound of rubble from the collapse of the WTC buildings and
surrounding infrastructure and the geographic area of the collapsed buildings that was the source and
location of the long-burning fires.
Please specify location
Office of Chief Medical Examiner
Pier 6
Pier 25
Other Pier
Please specify
Transport barges
Please specify/describe
Other transportation vehicle(s)
Please specify/describe
Staten Island/Fresh Kills Landfill
Please specify/describe
Other
Please specify/describe
2. If the Claimant was a Responder at the Pentagon
Please identify the organization(s) for which the Claimant worked as a Responder during the period
beginning September 11, 2001 through May 30, 2002.
Federal Law Enforcement (FBI, etc)
US Corps of Engineers
US Corps of Engineers Contractor (EE&G)
US Corps of Engineers Contractor Phillips and Jordan
U.S. Coast Guard
National Guard
Secret Service
US Environmental Protection Agency
FEMA
Other Federal Agency Please Specify
Volunteer Organization (including Red Cross and Salvation Army).
Please Specify
Volunteer (non-affiliated)
Union member
Please Specify
Please specify union and local
Other
Please Specify
Please identify the location at the Pentagon site where the Claimant was present during the period
beginning September 11, 2001 through May 30, 2002
Address
Address
9510573022
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
3. If the Claimant was a Responder at the Shanksville, PA
Please identify the organization(s) for which the Claimant worked as a Responder during the period
beginning September 11, 2001 through May 30, 2002.
Federal Law Enforcement (FBI, etc)
US Corps of Engineers
US Corps of Engineers Contractor (EE&G)
US Corps of Engineers Contractor Phillips and Jordan
U.S. Coast Guard
National Guard
Secret Service
US Environmental Protection Agency
FEMA
Other Federal Agency Please Specify
Volunteer Organization (including Red Cross and Salvation Army) Please Specify
Volunteer (non-affiliated)
Please Specify
Union member
Please specify union and local
Other Please Specify
Please identify the location at the Pentagon site where the Claimant was present during the period
beginning September 11, 2001 through May 30, 2002
Address
Address
4. If the Claimant claims presence at the site based on residence within the NYC Exposure Zone
Please identify the address of the Claimant's residence during the period
beginning September 11, 2001 through May 30, 2002
Address
Address
7588557083
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
5. If the Claimant worked (as a non-Responder) cleaning buildings or performing maintenance
work within the NYC Exposure Zone
Identify the name, address, telephone number and email address of the Claimant's employer for the
period beginning September 11, 2001 through May 30, 2002 during which the Claimant is alleging
presence in the NYC Exposure Zone. If the Claimant had more than one employer during this time
period, please print a copy of this page and complete this section separately for each employer.
Employer
Employer's Address
Employer's Address
(
)
Telephone Number
-
Email Address
Please identify the name and address of the location where the Claimant worked.
Please complete this Part separately for each location.
Address
Address
6. If the Claimant worked (as a non-Responder) within the NYC Exposure Zone in a capacity
other than cleaning buildings or performing maintenance work
Identify the name, address, telephone number and email address of the Claimant's employer for the
period beginning September 11, 2001 through May 30, 2002 during which the Claimant is claiming
presence in the NYC Exposure Zone. If the Claimant had more than one employer during this time
period, please print a copy of this page and complete this section separately for each employer.
Employer
Employer's Address
Employer's Address
(
)
Telephone Number
-
Email Address
Please identify the name and address of the location where the Claimant worked.
Please complete this section separately for each location.
Address
Address
6580440052
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
7. If the Claimant attended school or a child care or adult care facility within the NYC
Exposure Zone.
Identify the name of the school or the child care or adult day care facility that the Claimant
attended in the NYC Exposure Zone for the period beginning September 11, 2001 through
May 30, 2002.
School/care facility name
School/care facility address
School/care facility address
(
)
Telephone Number
-
8. If the Claimant was present within the NYC Exposure Zone in some other capacity (e.g., as
a visitor).
Please describe why the Claimant was in the NYC Exposure Zone during the period
beginning September 11, 2001 through May 30, 2002:
Description
Description
Description
Description
Please identify the closest location within the NYC Exposure Zone where the Claimant
was present during the period beginning September 11, 2001 through May 30, 2002:
Building - identify address
Street - identify address/cross street
Subway/train/station - indentify location
Other - specify location
8000162524
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
A. Circumstances and Location of Presence at a 9/11 Crash Site (continued)
9. If the Claimant was present at the Pentagon site (as non-Responder).
Why was the Claimant present at the Pentagon site during the period beginning September
11, 2001 through May 30, 2002?
Worked at Pentagon
Attended meeting at Pentagon
Other Please explain
Identify the name, address, telephone number and email address of the Claimant's employer for
the period beginning September 11, 2001 through May 30, 2002 during which the Claimant is
claiming presence at the site.
Employer Name
Employer's Address
Employer's Address
(
Telephone Number
)
-
Email Address
Identify the location at the Pentagon site where the Claimant was present during the period beginning
September 11, 2001 through May 30, 2002.
Address
Address
Address
0818219537
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
B. Time and Duration of Presence at the Site.
Please identify on the lines below the specific days and number of hours for each day beginning
September 11, 2001 through May 30, 2002 that the Claimant asserts presence at the location
identified in Part II.A above (e.g., lived, worked, attended school or was otherwise present at a 9/11
crash site).
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Start Date: (mm/dd/yyyy)
Start Date: (mm/dd/yyyy)
Start Date: (mm/dd/yyyy)
Start Date: (mm/dd/yyyy)
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
Start Date:
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End Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
End Date: (mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
End Date:
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
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(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Hours
Location
Hours
Location
Hours
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Hours
Location
Hours
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Hours
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Hours
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Hours
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Hours
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Hours
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Hours
Location
Hours
Location
Hours
Location
Hours
Location
Hours
Location
C. Proof of Location and Time of Presence and Activities at the Site.
Please see the instructions and document checklist for an explanation of the documents that you
must submit to prove that the Claimant was present at a 9/11 crash site.
5349213816
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
PART III. INFORMATION ABOUT THE CLAIMANT'S PHYSICAL INJURY
Did the Claimant suffer physical harm as a result of one of the air crashes and/or the debris
Yes
No
removal?
If no, proceed to Part IV
If yes,
Has the Claimant been diagnosed with any of the following conditions? Please indicate
all that apply and answer questions 1 - 7 for each condition on the following pages.
Make an additional copy of pages 16 - 18 for each condition being reported.
01 - Interstitial lung diseases
02 - Chronic respiratory disorder – Fumes/Vapors
03 - Asthma
04 - Reactive airways dysfunction syndrome (RADS)
05 - WTC-exacerbated chronic obstructive pulmonary disease (COPD)
06 - Chronic cough syndrome
07 - Upper airway hyperreactivity
08 - Chronic rhinosinusitis
09 - Chronic nasopharyngitis
10 - Chronic laryngitis
11 - Gastroesophageal reflux disorder (GERD)
12 - Sleep apnea exacerbated by or related to the above conditions.
13 - Low back pain
14 - Carpal tunnel syndrome (CTS)
15 - Other musculoskeletal disorders
16 - Traumatic injury
17 - Other. Please specify
If you are claiming multiple conditions, please use the condition number to indicate for
which condition the questions are being answered on the following pages.
Please remember to submit all pages.
7324024833
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Claimant's SSN or Nat'l ID #
OMB 1123-0012
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Did the Claimant suffer physical harm as a result of one of the air crashes and/or the debris
removal? (continued)
Condition Number:
Please answer the following questions.
1. When did the Claimant first discover this injury or condition?
/
/
/
/
/
/
(mm/dd/yyyy)
2. When was the Claimant first treated by a medical
professional for this injury or condition?
3. When was the Claimant diagnosed with this injury or
condition?
(mm/dd/yyyy)
(mm/dd/yyyy)
4. If the Claimant was diagnosed with this injury or
condition prior to September 11, 2001, has the
condition worsened since September 11, 2001?
Yes
No
5. Has the Claimant been treated for this injury or condition
under the WTC Health Program which commenced on
July 1, 2011?
Yes
No
NA
What is the WTC Health Program?
The WTC Health Program, which is operated by the National Institute for
Occupational Safety and Health (NIOSH), was established pursuant to Title
I of the Zadroga Act and commenced on July 1, 2011. The WTC Health
Program provides medical diagnostic and treatment services for eligible
individuals with specified injuries or conditions determined to be
aggravated, contributed to, or caused by the September 11, 2001 terrorist
attacks or the subsequent debris removal efforts. The WTC Health
Program includes a nationwide network of health care providers for eligible
individuals living outside the New York metropolitan area. As of July 1,
2011, the WTC Health Program assumed the functions and goals of two
prior programs: the WTC Medical Monitoring and Treatment Program for
responders and recovery and cleanup workers which included a nationwide
network of health care providers who provided services for responders
living outside the New York metropolitan area, and the WTC Environmental
Health Center Community Program for eligible residents, students, and
others in the community. Please refer to the Instructions for more
information about the WTC Health Program and the two previous
programs.
continued on next page
9305198117
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
Please restate the conditon number being reported on
Condition Number:
If, yes,
At what medical location in the WTC Health Program was the Claimant treated for this injury or condition?
Fire Department of New York (FDNY)
Long Island Jewish Medical Center
Mount Sinai School of Medicine - Annenberg Building (New York, NY)
Mount Sinai School of Medicine - Richmond University Medical Center (Staten Island, NY)
Nationwide Network of Health Care Providers Please specify
New York University, Bellevue Hospital Center
State University of New York, Stony Brook - Suffolk County (Islandia, NY)
State University of New York, Stony Brook - Nassau County (Garden City, NY)
State University of New York, Stony Brook - Nassau County (Hicksville, NY)
State University of New York, Stony Brook - Kings County (Brooklyn, NY)
University of Medicine and Dentistry of New Jersey
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Bellevue Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Elmhurst Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Gouverneur Healthcare Services
6. Was the Claimant treated for this injury or condition prior to July 1, 2011 under the WTC Medical Monitoring
and Treatment Program (including a nationwide network of health care providers who provided services for
responders living outside of the New York City metropolitan area) or the WTC Environmental Health Center
Yes
No
Community Program?
If yes,
At what medical location was the Claimant treated for this injury or condition?
City University of New York/Queens College
Fire Department of New York (FDNY)
Mount Sinai School of Medicine - Annenberg Building (New York, NY)
Mount Sinai School of Medicine - Richmond University Medical Center (Staten Island, NY)
Nationwide Network of Health Care Providers Please specify
New York University, Bellevue Hospital Center
State University of New York, Stony Brook - Suffolk County (Islandia, NY)
State University of New York, Stony Brook - Nassau University Medical Center (East Meadow, NY)
State University of New York, Stony Brook - Nassau County (Hicksville, NY)
University of Medicine and Dentistry of New Jersey
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Bellevue Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Elmhurst Hospital Center
World Trade Center Environmental Health Center (NYC Health and Hospitals Corporation)
- Gouverneur Healthcare Services
2168216365
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Claimant's SSN or Nat'l ID #
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OMB 1123-0012
Please restate the conditon number being reported on
Condition Number:
7. Was the Claimant treated for this injury or condition in another entity/program or by a private
physician?
Yes
No
If yes:
Please identify the outside physician(s) or other entity/program treating the Claimant
for this condition. Include the contact information (name, address, telephone number,
email address) of the outside physician or other entity/program.
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
(
)
-
)
-
Telephone Number
Email Address
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
(
Telephone Number
Email Address
If you are asserting additional conditions, please print copies of pages 16 - 18 and complete the
questions for each condition asserted. Please remember to submit all pages.
2159302956
18
Claimant's SSN or Nat'l ID #
-
OMB 1123-0012
-
PART IV. ATTESTATIONS AND CERTIFICATIONS FOR ELIGIBILITY
FORM
A. PRIVACY ACT NOTICE
The Department of Justice is authorized to collect this information by the September 11th Victim Compensation Fund of
2001, Title IV of Public Law 107-42, Air Transportation Safety and System Stabilization Act, 49 U.S.C. § 40101 note, as
amended by the James Zadroga 9/11 Health and Compensation Act of 2010, Title II of Public Law 111-347. The
information you submit in your claim is for official use by the U.S. Department of Justice for the purposes of determining
your eligibility for and the amount of compensation you may receive under your claim to the Victim Compensation Fund.
Provision of this information is voluntary; however, failure to provide complete information may result in a delay in
processing or a denial of your claim. Information you submit regarding your claim may be disclosed by the Government
only in accordance with the provisions of the Privacy Act.
I Authorize the U.S. Department of Justice to disclose any records or information relating to my Victim Compensation
Fund claim for the purpose of determining qualification and/or compensation of my claim to: agency contractors assisting
in the administration of the Victim Compensation Fund; other federal, state, or local agencies, including the Department of
Treasury and NIOSH; and other individuals or entities having information related to the claim, such as physicians, medical
service providers, insurers, and employers.
/
Signature of Claimant or Authorized Representative
(e.g. legal guardian)
Date (mm/dd/yyy)
Print Name
Relationship to Claimant
B. P ROOF
OF
/
D ISMISSAL OF ANY L AW SUIT
Have you or any dependent, spouse, or beneficiary of the Claimant filed a lawsuit (or been a party to a
lawsuit) in any Federal or State court relating to or arising out of damages sustained as a result of the
terrorist-related aircraft crashes of September 11, 2001 or for damages arising from or related to debris
removal (other than a lawsuit to recover collateral source obligations or a lawsuit against any person who is a
knowing participant in any conspiracy to hijack any aircraft or commit any terrorist act)?
Yes
No
If Yes,
Was the lawsuit withdrawn or dismissed on or before January 2, 2012?
Yes
No
Was the lawsuit settled on or before January 2, 2011?
Yes
No
Was the lawsuit settled in part on or before January 2, 2011?
Yes
No
Do not know
If yes:
Was the portion of the lawsuit that was not settled on
or before January 2, 2011 dismissed on or before
January 2, 2012?
Yes No
Initial here:
6620533858
19
-
Claimant's SSN or Nat'l ID #
OMB 1123-0012
-
C. A CKNOWLEDGEMENT OF W AIVER OF R IGHTS
I hereby acknowledge that by submission of a substantially complete Eligibility Form, I am waiving the
right to file a lawsuit (or be a party to a lawsuit) in any federal or state court for damages sustained as a
result of the terrorist-related aircraft crashes of September 11, 2001 or for damages arising from or related
to debris removal.
Please note this Waiver of Rights could apply to the rights of individuals other than the Claimant. This
waiver does not apply to lawsuits to recover collateral source obligations or to a lawsuit against any
person who is a knowing participant in any conspiracy to hijack any aircraft or commit any terrorist attack.
/
Signature of Claimant or Authorized Representative
(e.g. legal guardian)
/
Date (mm/dd/yyy)
If not Claimant:
Print Name
D. D ECLARATION
Relationship to Claimant
OF
A UTHORITY TO A CT ON M INOR C LAIM ANT ’S B EHALF
Please complete this Section only if you completed Part I.B and are submitting this claim on behalf
of a minor.
I hereby declare that the Claimant,
authorized to act on the Claimant's behalf because: (sign one)
, is a minor and that I am legally
(1) I am the Claimant's parent, I have sole legal custody of the Claimant, and the Claimant does not have
a legal guardian. I declare under penalty of perjury that the foregoing is true and correct.
Executed on this
day of
, 201
Signature of Parent
5459368123
20
.
Claimant's SSN or Nat'l ID #
D. D ECLARATION
OF
-
-
A UTHORITY TO A CT ON M INOR C LAIM ANT ’S B EHALF (CONTINUED )
(2) I am the Claimant's parent, I share legal custody or have joint custody of the Claimant with
, and the Claimant does not have a legal guardian.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this
day of
, 201
.
, 201
.
Signature of Parent
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this
day of
Signature of other person with joint legal custody of Claimant
(3) I am the Claimant's legal guardian. I declare under penalty of perjury that the foregoing is
true and correct.
Executed on this
, 201
day of
.
Signature of Guardian
(4) I am not the Claimant's parent but I have legal custody of the Claimant, the Claimant's parents
do not have legal custody of the Claimant, and the Claimant does not have a legal guardian. I
declare under penalty of perjury that the foregoing is true and correct.
Executed on this
, 201
day of
Signature of Authorized Representative
(Relationship to Claimant)
2165383121
21
.
OMB 1123-0012
Claimant's SSN or Nat'l ID #
E . A U T H O R IZ AT IO N
OF
R E LE AS E
-
-
OMB 1123-0012
O F I N F O R M AT IO N
I Authorize the U.S. Department of Justice to obtain any information relating to my claim under the September
11th Victim Compensation Fund of 2001 (Victim Compensation Fund or VCF) for the purpose of evaluating my
claim for compensation to the VCF from individuals, employers, hospitals, medical service providers, other
federal, state or local agencies including the Social Security Administration and the Internal Revenue Service,
the World Trade Center Health Program (WTCHP), the National Institute for Occupational Safety and Health
(NIOSH), the Clinical Centers of Excellence under the WTCHP, the Nationwide Network of health care
providers under the WTCHP, the Fire Department of New York, the New York City Police Department, the New
York Office of Payroll Administration, the New York City Employees' Retirement System, the Teachers'
Retirement System of the City of New York, the New York City Police Pension Fund, the New York Fire
Department Pension Fund, the New York City Board of Education Retirement System, the New York State
Workers' Compensation Board, the State of New Jersey Department of Labor and Workforce Development,
Division of Workers' Compensation, the State of Connecticut Department of Social Services, Bureau of
Rehabilitation Services (formerly the State of Connecticut Workers' Compensation Commission), the Port
Authority of New York and New Jersey, the New York City Office of the Chief Medical Examiner, New York City
Health and Hospitals Corporation, Child Health Plus, Family Health Plus, Medicaid, the WTC Captive
Insurance Company, Inc., the Allocation Neutral for the World Trade Center Litigation Settlement, or other
sources having information relating to my claim. This information may include, but is not limited to, medical,
government, and financial information (including pension records, pension files, or pension information) about
me or the Claimant whom I represent. The requested medical information may consist of my entire medical
records, which may include application or enrollment information, eligibility information, claims records, claim
status, patient medical records, patient histories, office notes (except psychotherapy notes), test results,
radiology studies, films, referrals, consults, billing records, insurance records, and records sent by other health
care providers. Disclosure requested will include otherwise confidential information. If records include claims
or other information pertaining to chronic diseases, behavioral health conditions, including alcohol or substance
abuse, communicable diseases, including HIV/AIDS, and/or genetic marker information, these records will be
included in the information made available to the Victim Compensation Fund.
I Recognize that signing this Authorization is voluntary and that my doctors and medical providers and any
other entity in possession of my health information may not condition treatment, payment, enrollment or
eligibility for benefits on whether I sign this Authorization. However, the VCF may not be able to evaluate my
claim if I do not authorize the release of my medical records.
I Further Recognize that health care providers are required by the Privacy Rule under HIPAA to protect my
health information. When they provide the information to the VCF it will not be protected by this same Privacy
Rule. However, the VCF, DOJ and NIOSH will continue to protect the confidentiality of my medical records to
the extent they are permitted to do so under another federal law, the Privacy Act. The VCF will not disclose my
identifiable health information that it receives under this Authorization without my written consent except where
authorized to do so by law.
I Further Authorize the U.S. Department of Justice to disclose any records or information relating to my Victim
Compensation Fund claim for the purpose of determining qualification and/or compensation of my claim to:
agency contractors assisting in the administration of the Victim Compensation Fund; other federal, state, or
local agencies, including the Department of Treasury and NIOSH; and other individuals or entities having
information related to the claim, such as physicians, medical service providers, insurers, and employers.
I Further Authorize the U.S. Department of Justice to publish the name of the Claimant filing a claim and for
whom compensation is sought.
I Further Authorize the release of information relating to my claim, where such information indicates a
violation or potential violation of law, including submission of fraudulent claims, to any civil or criminal law
enforcement authority or other appropriate agency charged with responsibility of investigating or prosecuting
such a violation.
9056416078
22
-
Claimant's SSN or Nat'l ID #
E. A UTHORIZATION OF R ELEASE OF INFORM ATION
OMB 1123-0012
-
(CONTINUED)
I Further Authorize individuals, entities, and federal, state and local agencies including NIOSH and the
WTCHP, having information pertinent to my claim to release such information to a duly accredited
representative of the Department of Justice during the review of my claim to the Victim Compensation
Fund, regardless of any previous agreement to the contrary. Copies of this authorization that show my
signature are as valid as the original release signed by me. I acknowledge that I have the right to revoke
this Authorization at any time, except to the extent that VCF and the entities listed above have already
acted based on this Authorization. I understand that to revoke this authorization, I must write to the VCF at
September 11th Victim Compensation Fund, P.O. Box 34500, Washington, D.C. 20043. I recognize that
this authorization is valid for six (6) years from the date signed or upon my written termination, whichever
is sooner.
I Certify that I am the person named below (Claimant to the Victim Compensation Fund or authorized
representative of the Claimant) and I authorize the release of information listed above. I understand that
the knowing and willful request for or acquisition of a record pertaining to an individual under false
pretenses is a criminal offense subject to a $5,000 fine.
By initialing, I acknowledge that the information described above may include mental health information and I
authorize the release of such information ____________.
/
Signature of Claimant or Authorized Representative(s)
(e.g. legal guardian)
Print Name
/
Date (mm/dd/yyyy)
Relationship to Claimant
F. CLAIMANT’S ACKNOWLEDGMENT OF ATTORNEY’S COMPLIANCE WITH LIMITATION ON
ATTORNEY FEES
If the Claimant has been represented by an attorney for services rendered in connection with this claim, the
Claimant must sign and date the following acknowledgement:
I hereby acknowledge that I have read and understand the provisions governing the limitation on attorney
fees as stated in the Instructions to this claim form, which, in general and with limited exceptions, provide that
my attorney, notwithstanding any contract, cannot charge me more than ten percent (10%) of any award
that may be paid on my claim, and that any expenses incurred by my attorney in connection with my claim,
other than those that are routinely incurred, cannot be charged to me unless they have been approved by the
Special Master.
/
Signature of Claimant or Authorized Representative(s)
(e.g. legal guardian)
Print Name
Date (mm/dd/yyyy)
Relationship to Claimant
1093170102
23
/
-
Claimant's SSN or Nat'l ID #
G. A UTHORIZATION FOR C OMM UNICATION
AND
OMB 1123-0012
-
C ORRESPONDENCE
If an attorney or other authorized individual is assisting the Claimant (or authorized representative of the
Claimant) with this claim and the Claimant (or authorized representative of the Claimant) wants to
authorize the Victim Compensation Fund to communicate with this individual, please sign and date the
following authorization.
Indicate If you would like to receive a copy of all VCF correspondence regarding your claim.
Note that if you do not check this box, the VCF will not be authorized to contact
here
you directly regarding your claim.
I Authorize the Special Master, the Special Master's designees, the United States Department of Justice or
agency contractors assisting in the administration of the Victim Compensation Fund to contact my attorney or
other persons authorized to act on my behalf (if identified in Part I.C.) if the Special Master needs additional
information or clarification about my claim.
/
Signature of Claimant or Authorized Representative
(e.g. legal guardian)
/
Date (mm/dd/yyyy)
If not Claimant:
Print Name
H. C ERTIFICATION
Relationship to Claimant
OF
A CCURACY OF I NFORM ATION
I hereby certify that the information provided in this application and any documents provided in support of this
claim are true and accurate to the best of my knowledge, and I agree that any payment made by the VCF is
expressly conditioned upon the truthfulness and accuracy of the information and documentation provided in
support of the claim. Further, I understand that false statements or claims made in connection with this
application may result in fines, imprisonment and/or any other remedy available by law to the Federal
Government, and that claims that appear to be potentially fraudulent or to contain false information will be
forwarded to federal, state, and local law enforcement authorities for possible investigation and prosecution.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this
, 201
day of
Signature of Claimant or Authorized Representative
(e.g. legal guardian)
If not Claimant:
Relationship to Claimant
Print Name
8568626854
24
.
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
I. P APERW ORK R EDUCTION A CT N OTICE
An agency may not conduct or sponsor an information collection and a person is not required to respond to
a collection of information unless it contains a currently valid OMB approval number. We try to create forms
and instructions that are accurate, can be easily understood, and that impose the least possible burden on
you. The estimated average time to complete and file this application is 1.5 hours. If you have comments
regarding the accuracy of this estimate, or suggestions for making this form simpler, you can write to the
Office of the Special Master, U.S. Department of Justice, 950 Pennsylvania Ave, NW, Washington, DC
20530; OMB control number 1123-0012. (Do not mail your completed application to this address.)
0803569214
25
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Medical Records
Instructions for Claimant - Please list all doctors and health care providers who were involved in
diagnosing and treating your injury, as well as any other entities (e.g., insurance companies, workers'
compensation programs, pension programs) that may have medical information in Section 1. Please
copy this exhibit and complete if you need to list more than four health care providers or other entities.
Then, please print your name and address and sign in the block in Section 2.
When you sign this document, you give permission to your doctors, health care providers or other
entities listed below to disclose your health information to the September 11th Victim
Compensation Fund (VCF), the United States Department of Justice (DOJ), and the National
Institute for Occupational Safety and Health (NIOSH) for purposes of evaluating your claim for
compensation to the VCF.
Please note that you may revoke this Authorization at any time, except to the extent that VCF and the
providers listed below have already acted based on this Authorization. To revoke this authorization, you
must write to the providers or entities listed below and to the VCF at the address below. This
authorization is valid for six (6) years from the date signed or upon your written termination, whichever is
sooner.
Your doctors and medical providers may not condition treatment, payment, enrollment or eligibility for
benefits on whether you sign this Authorization. However, the VCF may not be able to evaluate your
claim if you do not authorize the release of your medical records.
Your providers and certain other entities are required by the Privacy Rule under HIPAA to protect your
health information. When they provide the information to the VCF it will not be protected by this same
Privacy Rule. However, the VCF, the DOJ and NIOSH will continue to protect the confidentiality of your
medical records to the extent they are permitted to do so under another Federal law, the Privacy Act. The
VCF will not disclose your identifiable health information that it receives under this Authorization without
your written consent except where authorized to do so by law.
Information to be disclosed to the Victim Compensation Fund includes, but is not limited to,
application or enrollment information, eligibility information, claims records, claim status, pension
records and files, entire patient medical records, patient histories, office notes (except
psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records,
insurance records, and records sent to your doctors and medical care providers by other health
care providers.
Disclosure requested will include otherwise confidential information. If records include claims or
other information pertaining to chronic diseases, behavioral health conditions, including alcohol or
substance abuse, communicable diseases, including HIV/AIDS, and/or genetic marker information, these
records will be included in the information made available to the VCF.
I understand that this authorization is voluntary. However, if you refuse to sign this authorization, the
VCF will not be able to process your claim for compensation.
8767092290
26
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Medical Records
By initialing, I acknowledge that the information described above may include mental health
information and I authorize the release of such information________.
I hereby authorize the person, carrier or other entity listed below to disclose confidential
information about the claimant listed below to the VCF, the DOJ and NIOSH:
Section 1 - Name, telephone number and email address for doctors, health care providers or other
entities.
Physician/Other Entity or Program:
Doctor/Provider/Entity Name
Doctor/Provider/Entity Address
Doctor/Provider/Entity Address
Suite Number
City
State/Province
Zip/Postal Code
(
)
-
(
)
-
Telephone Number
Email Address
Physician/Other Entity or Program:
Doctor/Provider/Entity Name
Doctor/Provider/Entity Address
Doctor/Provider/Entity Address
Suite Number
City
State/Province
Zip/Postal Code
Telephone Number
Email Address
0118456094
27
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Medical Records
I hereby authorize the person, carrier or other entity listed below to disclose confidential
information about the claimant listed below to the VCF, the DOJ and NIOSH:
Section 1 - Name, telephone number and email address for doctors, health care providers or other
entities continued.
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
(
)
-
(
)
-
Telephone Number
Email Address
Physician/Other Entity or Program:
Name
Address
Address
Suite Number
City
State/Province
Zip/Postal Code
Telephone Number
Email Address
The National Institute for Occupational Safety and Health
0695167105
28
-
Claimant's SSN or Nat'l ID #
OMB 1123-0012
-
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Medical Records
Section 2 - Claimant information and signature.
Claimant's Last Name
First Name
Middle Name
Mailing Address
Mailing Address
Apartment/Suite Number
City
State/Province
Zip/Postal Code
/
Social Security or National ID Number
/
(
Date of Birth (mm/dd/yyyy)
(
)
)
-
Telephone Number (Home)
-
(
Telephone Number (Work)
)
Telephone Number (Mobile)
Email Address
This information shall be sent to:
The September 11th Victim Compensation Fund
P.O. Box 34500
Washington, DC 20043
3057384673
29
-
-
Claimant's SSN or Nat'l ID #
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit A to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Medical Records
Section 2 - Claimant information and signature continued.
I Certify that I am the person named below (Claimant to the Victim Compensation Fund or authorized
representative of the Claimant) and I authorize the release of information listed above. I understand that the
knowing and willful request for or acquisition of a record pertaining to an individual under false pretenses is a
criminal offense subject to a $5,000 fine.
/
Signature of Claimant or Authorized Representative(s)
/
Date (mm/dd/yyyy)
If not Claimant:
Print Name
Relationship to Claimant
Type of coverage to which this authorization applies (the doctor, health care provider or other entity will
indicate all that apply)
Medical
Disability
Pharmacy
Long Term Care
Other Please specify/describe
6245417649
30
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit B1 to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Pension Records and Health Information
by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF PENSION AND HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name
Social Security Number
Patient Address
I, or my authorized representative, request that pension and health information regarding my care and
treatment be released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE,
MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED
INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health
information described below includes any of these types of information, and I initial the line on the box in
Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment
information, the recipient is prohibited from redisclosing such information without my authorization unless
permitted to do so under federal or state law. I understand that I have the right to request a list of people
who may receive or use my HIV-related information without authorization. If I experience discrimination
because of the release or disclosure of HIV-related information, I may contact the New York State
Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212)
306-7450. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed
below. I understand that I may revoke this authorization except to the extent that action has already been
taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health
plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted
above in Item 2), and this redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION
OR MEDICAL CARE OR PENSION INFORMATION WITH ANYONE OTHER THAN THE ATTORNEY
OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
9389231140
31
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit B1 to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Pension Records and Health Information
by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF PENSION AND HEALTH INFORMATION PURSUANT TO HIPAA
7. Name and address of health provider, pension fund, or other entity to release this information:
New York Office of Payroll Administration (OPA)
Room 200N
One Centre Street
New York, NY 10007
New York City Police Pension Fund (POLICE)
233 Broadway, 19th Floor
New York, NY 10279
New York Fire Department Pension Fund (FIRE)
9 MetroTech Center
Brooklyn, NY 11201
New York City Employees' Retirement System (NYCERS)
335 Adams Street, Suite 2300
Brooklyn, NY 11201-3724
Teachers' Retirement System of the City of New York (TRS)
55 Water Street
New York, NY 10041
New York City Board of Education Retirement System (BERS)
65 Court Street, 16th Floor
Brooklyn, NY 11201-4965
8. Name and address of person(s) or category of person to whom this information will be sent:
The September 11th Victim Compensation Fund of 2001
P.O. Box 34500
Washington, DC 20043
The United States Department of Justice
950 Pennsylvania Avenue, NW
Washington, DC 20530
2148448584
32
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit B1 to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Pension Records and Health Information
by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF PENSION AND HEALTH INFORMATION PURSUANT TO HIPAA
9(a). Specific information to be released:
Complete Pension File, including, but not limited to:
Information regarding the type of pension awarded
(ADR, ODR or service), the amount, and whether or
not the benefit was awarded pursuant to the WTC
Disability Law.
Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Mental Health Information
HIV Related Information
Authorization to Discuss Health or Pension Information
9(b).
By initialing here
, I authorize
(Initials)
(Name of individual health care provider, pension fund or other entity)
to discuss my health or pension-related information with my attorney, or a governmental agency,
listed here:
the September 11th Victim Compensation Fund and the United States Department of Justice
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
11. Date or event on which this authorization will
expire:
At request of individual
Other: To evaluate my claim
for compensation with the September
11th Victim Compensation Fund
Six (6) years from the date of signature or upon
my written termination
12. If not the claimant, name of person signing
form:
13. Authority to sign on behalf of claimant:
All items on this form have been completed and my questions about this form have been answered.
In addition, I have been provided a copy of the form.
Date:
Signature of claimant or representative authorized by law
3967206788
33
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit B2 to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Health Information by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
Patient Name
Date of Birth
Social Security Number
Patient Address
I, or my authorized representative, request that health information regarding my care and treatment be
released as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE,
MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED
INFORMATION only if I place my initials on the appropriate line in Item 9(a). In the event the health
information described below includes any of these types of information, and I initial the line on the box in
Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment
information, the recipient is prohibited from redisclosing such information without my authorization unless
permitted to do so under federal or state law. I understand that I have the right to request a list of people
who may receive or use my HIV-related information without authorization. If I experience discrimination
because of the release or disclosure of HIV-related information, I may contact the New York State
Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212)
306-7450. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed
below. I understand that I may revoke this authorization except to the extent that action has already been
taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health
plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted
above in Item 2), and this redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION
OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL
AGENCY SPECIFIED IN ITEM 9 (b).
0953462166
34
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit B2 to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Health Information by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
7. Name and address of health provider or other entity to release this information:
8. Name and address of person(s) or category of person to whom this information will be sent:
The September 11th Victim Compensation Fund of 2001
P.O. Box 34500
Washington, DC 20043
The United States Department of Justice
950 Pennsylvania Avenue, NW
Washington, DC 20530
8089196911
35
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit B2 to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Health Information by New York Individuals and Entities
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
9(a). Specific information to be released:
Medical Record from (insert date)
to (insert(date)
Entire Medical Record, including patient histories, office notes (except psychotherapy
notes), test results, radiology studies, films, referrals, consults, billing records, insurance
records, and records sent to you by other health care providers.
Include: (Indicate by Initialing)
Alcohol/Drug Treatment
Other:
Mental Health Information
HIV Related Information
Authorization to Discuss Health Information
9(b).
By initialing here
(Initials)
, I authorize
(Name of individual health care provider)
to discuss my health information with my attorney, or a governmental agency, listed here:
the September 11th Victim Compensation Fund and the United States Department of Justice
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
11. Date or event on which this authorization will
expire:
At request of individual
Other: To evaluate my claim
for compensation with the September
11th Victim Compensation Fund
Six (6) years from the date of signature or upon
my written termination.
12. If not the patient, name of person signing form:
13. Authority to sign on behalf of patient:
All items on this form have been completed and my questions about this form have been answered.
In addition, I have been provided a copy of the form.
Date:
Signature of patient or representative authorized by law
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which
reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.
5546235459
36
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit C to the Eligibility Form For Personal Injury Claimants
Attorney Certification of Compliance with Provision on Limitation on Attorney Fees
(Section 104.81)
If Claimant has been represented by an attorney for services rendered in connection with this claim,
Claimant's attorney must complete the following certification:
I hereby certify that:
(1) The amount I have charged or will charge for the services I have rendered in connection with this
claim, including expenses routinely incurred in the course of providing legal services, is not more than 10
percent of an award that might be paid on this claim; AND
(2) I have not charged nor will I charge for any expenses incurred in connection with this claim that are
not routinely incurred in the course of providing legal services, unless the Special Master has approved
such expenses; AND
(3) One of the following statements is true concerning a civil action brought by or on behalf of the
Claimant for damages sustained as a result of the terrorist-related aircraft crashes of September 11, 2001
or for damages arising from or related to debris removal (excluding civil actions to recover collateral
source obligations or against any person who is a knowing participant in any conspiracy to hijack or
commit any terrorist act) that was commenced after December 22, 2003 in which a release of all claims in
such action was tendered prior to January 2, 2011:
I did not charge a legal fee in connection with a settlement of this Claimant's claim(s) in
such an action; OR
I charged a legal fee in connection with a settlement of this Claimant's claim(s) in such
an action that was 10 percent or more of the aggregate amount of compensation
awarded though such settlement, and I have not charged nor will I charge for any
services rendered in connection with this claim with the VCF; OR
I charged a legal fee in connection with a settlement of this Claimant's claim(s) in such
an action that was less than 10 percent of the aggregate amount of compensation
awarded though such settlement, and the amount I have charged or will charge for the
services I have rendered in connection with this claim with the VCF does not exceed
the difference between 10 percent of such aggregate amount and the total amount of
all legal fees I charged for services rendered in connection with such settlement.
I declare under penalty of perjury that the foregoing is true and correct.
Executed on this
, 201
day of
.
Signature of Attorney
Attorney's Name
Attorney's Firm/Address
Attorney's Firm/Address
1757555432
37
-
Claimant's SSN or Nat'l ID #
-
OMB 1123-0012
September 11th Victim Compensation Fund of 2001
Exhibit D to the Eligibility Form For Personal Injury Claimants
Attorney Request for Approval For Charge of Non-Routine Expenses
If the Claimant (or Claimant's authorized representative) is represented by an attorney and the attorney is
seeking expenses incurred in connection with the claim other than those that are routinely incurred in the
course of providing legal services ("non-routine expenses"), the attorney must request the approval of such
expenses by the Special Master. The Special Master will review such requests on a case-by-case basis.
Indicate here if you are seeking non-routine expenses in connection with
this claim and attach a statement explaining the expenses for which you
seek approval and why they should be approved.
/
/
Date (mm/dd/yyyy)
Signature of Attorney
Attorney's Name
Attorney's Firm/Address
Attorney's Firm/Address
1297328204
38
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - PERSONAL INJURY CLAIMANTS
In order to process your claim, we need certain supporting documents. This checklist will help you compile
those documents. Please categorize your documents by the section of the claim form for which they are being
submitted. You are strongly encouraged to upload your documents electronically, which will allow a more
efficient claims process. If you are submitting a hard copy claim form and would like to upload documents
electronically, you will need to register at www.VCF.gov. Once your hard copy claim form is received,
processed, and loaded to the electronic system, you will have the ability to upload documents. If you do not
have access to electronic copies of documents or do not wish to register at www.VCF.gov, you may submit
hard copies of those documents by mail. To do so, please print this form and on the printed copy, mark the
appropriate boxes in the "Mailed" column for each section that you are submitting. Then send the documents
along with a copy of this form, by mail to September 11th Victim Compensation Fund; P.O. Box 34500;
Washington, DC 20043. The Claimant's Social Security Number or National ID Number should be written on
the top of all documents submitted by mail. For your records, you should keep a copy of all documents
submitted by mail to the VCF.
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part I.B. Information about the Claimant's Guardian
or Other Authorized Representative (If Applicable)
Documentation showing that the Claimant's
guardian or other authorized representative
has authority to act on behalf of a minor or
incapacitated Claimant. Examples include the
following:
Parent(s) of a Minor Claimant must submit:
(1) Claimant's birth certificate; and
(2) Court order granting one parent sole
custody of Claimant (if applicable)
Guardian or Other Person with Legal Custody
of a Minor Claimant must submit:
(1) Court order granting custody or appointing
guardianship; or
(2) Will or deed appointing guardianship
Guardian of a Non-Minor Claimant must
submit:
(1) Court order appointing guardianship
9895454510
39
Submission
Complete
For Internal
Use Only
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - PERSONAL INJURY CLAIMANTS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part I.E. Information about the Claimant's
Participation in Lawsuits Related to
September 11, 2001 (If Applicable)
If the lawsuit has been withdrawn, please
submit the notice or motion of withdrawal.
That withdrawal must be filed on the relevant
court docket on or before January 2, 2012.
Please note that you must also submit the final
order of the court confirming withdrawal in
order for the VCF to issue payment on your
claim if you are determined to be eligible.
If the lawsuit has been settled and released,
please submit a copy of the settlement
agreement and release. The documents you
submit must show the date of the settlement
and release, the total settlement amount, and
the medical condition that was approved for
payment under the settlement.
If the attorney of the Claimant or
Claimant's dependent, spouse or
beneficiary signed and submitted the
release, you must also provide a copy
of the retainer agreement with the
attorney in the settled lawsuit as proof
that the attorney was authorized to sign
the release.
If the lawsuit has been dismissed, please
submit the order of dismissal.
If you have filed a lawsuit or claim for
compensation for the claimed condition with
any court or bankruptcy trust for any
respiratory injury or disease due to exposure
unrelated to September 11, 2001 (e.g.,
asbestos), please submit information on the
action or claim (court/trust, year filed, docket
number, injury/disease claimed) and
documentation of any judgment, settlement or
trust compensation.
7184405920
40
Submission
Complete
For Internal
Use Only
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - PERSONAL INJURY CLAIMANTS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part II. Information About The Claimant's
Presence at a 9/11 Crash Site Between
September 11, 2001 and May 30, 2002
Please submit written proof showing the Claimant was present at the
site. Examples of acceptable proof include the following:
Responders
Employer records confirming employment with an organization or entity
that was responsible for rescue and recovery, clean up, transportation of
debris, and confirming that the Claimant was present at the site,
including an official personnel roster, site credentials or a pay stub; OR
Contemporaneous documentation of presence - such as orders,
instructions, confirmation of tasks performed, contemporaneous medical
records, or contemporaneous records of federal, state, city or local
government.
Presence Claimed Based on Residence
Proof of residence in the area during the relevant time period such as (i)
rent receipts, mortgage receipts, or utility bills and (ii) proof that the
Claimant was physically present at the residence at some point between
September 11, 2001 and May 30, 2002, which could include at least two
(2) sworn and notarized affidavits (or unsworn statements complying with
28 U.S.C. 1746 ) from co-habitants, landlords, doormen, or neighbors.
Presence Claimed Based on Non-Responder Work in NYC Exposure
Zone or at the Pentagon
Employment records documenting employment and presence in the NYC
Exposure Zone or at the Pentagon; OR
Contemporaneous documentation of presence - such as
contemporaneous medical records, or contemporaneous records of
federal, state, city or local government.
Presence Claimed Based on School/Care Facility Attendance
School or day care records confirming enrollment / attendance during the
period.
Presence in the NYC Exposure Zone in some other capacity (e.g. as
a visitor)
Contemporaneous documentation of presence - such as
contemporaneous medical records, or contemporaneous records of
federal, state, city or local government.
Note: At least two (2) sworn and notarized affidavits (or unsworn
statements complying with 28 U.S.C. 1746 ) regarding the presence of
the Claimant from persons who can attest to the Claimant's presence at
a 9/11 crash site will serve as acceptable proof only if other official or
"primary" forms of proof (such as those listed above) are not available
and the Fund determines that such affidavits are sufficiently reliable.
2441216448
41
Submission
Complete
For Internal
Use Only
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - PERSONAL INJURY CLAIMANTS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part III. Information About the Claimant's Physical Injury
For any claimed injuries or conditions that have been
certified for treatment under the WTC Health Program after
July 1, 2011:
The VCF may be able to obtain the necessary records
directly from the WTC Health Program. It is possible
that the VCF will need additional records and if so, the
VCF will notify you and provide instructions.
For any claimed injuries or conditions that have been treated
by physicians or programs other than the WTC Health
Program:
You will need to provide certified contemporaneous
medical records and documents created by or at the
direction of the medical professional(s) who provided
the medical care.
Your private physician(s) will need to complete certain
medical history forms if you are not getting or will not be
seeking treatment under the WTC Health Program. The
VCF will send the appropriate forms to your physician to
complete. Your physician may submit those forms
directly to the VCF at September 11th Victim
Compensation Fund; P.O. Box 34500; Washington, DC
20043. Once those forms are submitted, you should
update this document checklist to confirm submission
of those documents.
Note: The documentation should include proof of when each
injury or condition was first treated by a medical professional.
Other Documentation in Support of
Eligibility: Parts I-III (optional)
Other documentation you have included in support of
Parts I-III
Other (please describe)
Other (please describe)
0341179836
42
Submission
Complete
For Internal
Use Only
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - PERSONAL INJURY CLAIMANTS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Part IV. Attestations and Certifications
Please print Part IV and Exhibits A-D of the claim form, sign where
appropriate, and mail all pages of the Part (including pages you do not
need to sign) to the VCF at September 11th Victim Compensation
Fund; P.O. Box 34500; Washington, DC 20043. You must mail pages
with your original signature (no copies), but you should keep a copy
for your own records. If possible, please also upload copies of the
signed pages so that the VCF can begin processing your claim.
Part IV.A: Privacy Act Notice
Please sign this section. If you are the Claimant's authorized
representative (identified in Part I.B), please also print your name and
describe your relationship to the Claimant.
Part IV.B: Certification of Dismissal of Lawsuit
Please initial in the applicable space
Part IV.C: Acknowledgment of Waiver of Rights
Please sign this section. If you are the Claimant's authorized
representative (identified in Part I.B), please also print your name and
describe your relationship to the Claimant.
Part IV.D: Declaration of Authority to Act on Claimant's Behalf (If
Applicable)
Only complete this section if you are submitting this claim on behalf of a
Claimant under the age of 18.
Part IV.E: Authorization for Release of Information
Please sign this section. If you are the Claimant's authorized
representative (identified in Part I.B), please also print your name and
describe your relationship to the Claimant.
Part IV.F: Claimant's Acknowledgement of Attorney's Compliance
with Limitation on Attorney's Fees (If Applicable)
Only complete this section if an attorney provided legal services in
connection with this claim.
Part IV.G: Authorization for Communication and Correspondence
(If Applicable)
Only complete this section if an attorney or someone else identified in
Part I.C is assisting in the submission of this claim and if you want the
VCF to communicate with this person about your claim.
Part IV.H: Certification of Accuracy of Information
Please sign this section. If you are the Claimant's authorized
representative (identified in Part I.B), please also print your name and
describe your relationship to the Claimant.
3946142302
43
Submission
Complete
For Internal
Use Only
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - PERSONAL INJURY CLAIMANTS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Exhibits A - D
Exhibit A: Authorization for Release of Medical
Records
Please identify all doctors and health care providers who were involved
in diagnosing and treating your injury, as well as any other entities (e.g.,
insurance companies, workers' compensation programs, pension
programs) that may have medical information relevant to your claim.
Then complete your own contact information and sign and date the
signature page. If you are the Claimant's authorized representative
(identified in Part I.B), please also print your name and describe your
relationship to the Claimant.
Exhibit B1: Authorization for Release of Pension
Records and Health Information by New
York Individuals and Entities (If
Applicable)
You must complete this exhibit if you have been awarded a pension by
one of the following New York pension funds:
New York City Police Pension Fund (POLICE)
New York Fire Department Pension Fund (FIRE)
New York City Employees' Retirement System (NYCERS)
Teachers' Retirement System of the City of New York (TRS)
New York City Board of Education Retirement System (BERS)
To complete this exhibit:
Complete the boxes at the top of the page
Check the appropriate box in Question #7
Check the "Other" box in Question #9(a)
In Question #9(b), initial in the appropriate place and write the
name of the pension
Complete Question #12 and Question #13
Sign and date the form
Exhibit B2: Authorization for Release of Health
Information by New York Individuals and
Entities (If Applicable)
You must complete a copy of this exhibit for any medical provider you
identified in Exhibit A that is located in New York state. You must also
complete a copy of this exhibit for any other doctors, facilities,
hospitals, entities or individuals in New York state that have medical
information that is relevant to your claim. You should complete a
separate copy of this exhibit for each individual and entity.
To complete this exhibit:
Complete the boxes at the top of the page
Write the name and address of the individual or entity in
Question #7
In Question #9(a), initial in the three spaces next to
"Alcohol/Drug Treatment," "Mental HealthInformation" and
"HIV-Related Information."
In Question #9(b), initial in the appropriate place and write the
name of the individual or entity
Complete Question #12 and Question #13
Sign and date the form
3833506806
44
Submission
Complete
For Internal
Use Only
Claimant's SSN or Nat'l ID #
-
-
OMB 1123-0012
ELIGIBILITY FORM SUPPORTING DOCUMENTATION CHECKLIST - PERSONAL INJURY CLAIMANTS
Supporting Documentation for Eligibility
Form: Parts I-IV
Mailed
Exhibits A - D (continued)
Exhibit C: Attorney Certification of Compliance with
Provision on Limitation on Attorney's Fees
(if Claimant is represented by attorney)
This section must be completed by any attorney that is
charging for legal services provided in connection with
this claim. If an attorney has not assisted with this claim,
you do not need to complete this section. [Attorneys that
have provided pro bono assistance with this claim do not
need to complete this Exhibit]
Exhibit D: Attorney Request for Approval for Charge
of Non-Routine Expenses
This section should not be completed unless an attorney
that provided legal services in connection with this claim
seeks to charge the Claimant (or Claimant's
representative) for non-routine expenses. If the attorney
seeks non-routine expenses, a statement explaining the
non-routine expenses and why they should be approved
should be submitted with this Exhibit.
2728060487
45
Submission
Complete
For Internal
Use Only
| File Type | application/pdf |
| Author | woody.bailey |
| File Modified | 2011-10-27 |
| File Created | 2011-10-27 |