Form 1 Additional Documentation and Certification

Please check the box of the statement that applies to your case and return to the CICP in
the enclosed envelope. Select only one option below.
I will not submit any more documentation. Please review my file for medical eligibility
based on what has already been submitted, and do not wait the 60 days outlined in
CICP’s letter. The CICP will determine medical eligibility after receipt of this form and
inform the requester of the result and next steps.

My medical providers will update my CICP file by sending additional medical records to
CICP. I will contact them and ask them to send any recent records that have not yet been
sent and/or any records listed as missing in CICP’s letter that came with this form. I
understand that the CICP will provide 60 days from the date of the letter for the
submission of these records. The CICP will determine medical eligibility after this 60
day period and inform the requester of the result and next steps.

____________________________
Name of Requester (Please print)

____________________________
Signature

_______________________
CICP Case Number