5 Compensation Attachment 1

ATTACHMENT 1
Countermeasures Injury Compensation Program (CICP)
Documentation Required to Reimburse or Pay for Medical Expenses and/or
Lost Employment Income
To calculate the benefits to be reimbursed or paid for medical services and/or lost employment
income, the CICP requires that you submit specific documentation. The documentation that you
submit will depend on the benefits requested and third-party coverage you may have.
For each of the two sections below, please choose one of the descriptions that best fits your
situation.
Section I. Unreimbursed Medical Expenses
Choose either A, B or C and submit the requested documents described in that section.
A. If you are not requesting any payment or reimbursement for unreimbursed medical
expenses, please do the following:


Complete Option 1 of Attachment 2 - “Certification of Status: Unreimbursed
Medical Expenses,” sign and date the form, and submit it to the CICP.

B. If you are requesting payment or reimbursement for unreimbursed medical expenses
related to the countermeasure injury and you DO NOT have any third-party payers of
these expenses (private insurance company, employer, another government program,
etc.), please do the following:


Complete Option 2 of Attachment 2 - “Certification of Status: Unreimbursed Medical
Expenses,” and sign and date the form.



Gather your latest itemized statement(s), bill(s), and/or receipt(s) from each
healthcare provider (e.g., clinic, hospital, doctor’s office, or pharmacy) where you
sought medical services or items for the covered injury or health complications from
that injury. These documents must indicate the amount that was paid and the amount
that may still be owed.



Submit all of the documents described above to the CICP.

C. If you are requesting payment or reimbursement for unreimbursed medical expenses
and you DO have third-party payers for all or part of your medical expenses related to
the countermeasure injury (private insurance company, employer, another government
program, etc.), please do the following:


Complete Option 3 of Attachment 2 - “Certification of Status: Unreimbursed
Medical Expenses,” and sign and date the form.



Write a list of all third-party payers, including, but not limited to: Medicare,
Medicaid, the Department of Veterans Affairs (VA), military treatment facilities,
health insurance companies, or health maintenance organizations, which may have an
obligation to pay for or provide medical services or items. This list must include the
address, phone number, and account and plan number for each third-party payer.
Please ensure the list is legible and organized as described because not doing so could
delay the calculation of benefits.



Gather documentation from each third-party payer (e.g., an Explanation of Benefits
from your health insurance company) expected or obligated to pay for the medical
services or items used to diagnose or treat your covered injury or health
complications of that injury. Indicate the amounts that they have paid and amount
that you are required to pay to satisfy the bill.



Submit all of the documents described above to the CICP

Section II. Lost Employment Income
Choose either A, B or C and submit the requested documents described in that section.
A. If you are not requesting lost employment income benefits, please do the following:


Complete Option 1 of Attachment 3 - “Certification of Status: Lost Employment
Income Benefits,” sign and date the form, and submit it to the CICP.

B. If you are requesting payment or reimbursement for lost employment income
related to the countermeasure injury and you DO NOT have any third-party payers
for your lost employment income, please do the following:


Complete Option 2 of Attachment 3 - “Certification of Status: Lost Employment
Income Benefits,” and sign and date the form.



Gather documentation indicating the number of days (including partial days) of work
missed as a result of the covered injury or its health complications for which you lost
employment income (e.g., a time sheet from the pay period(s) showing work days
missed) and documentation of unpaid leave status.

 Gather your Federal tax return or pay stub(s) from all employers showing your gross
employment income at the time the covered injury was sustained.
 Gather your Federal tax return for the year in which the covered injury was sustained,
if you had dependents.
 Submit all of the documents described above to the CICP.

C. If you are requesting payment or reimbursement for lost employment income
related to the countermeasure injury and you do have third-party payers for your
lost employment income, please do the following:


Complete Option 3 of Attachment 3 - “Certification of Status: Lost Employment
Income Benefits,” and sign and date the form.



Write a list of all third-party payers providing lost employment income benefits to
you, including, but not limited to disability insurance or Worker’s Compensation.
This list must include the address, phone number, and case number for each thirdparty payer. Please ensure the list is legible and organized as described because not
doing so could delay the calculation of benefits.



Gather documentation indicating the number of days (including partial days) of work
missed as a result of the covered injury or its health complications for which you lost
income (e.g., a time sheet from the pay period(s) showing work days missed) and
documentation of unpaid leave status.



Gather your Federal tax return or pay stub(s) from all employers showing your gross
employment income at the time the covered injury was sustained.



Gather your Federal tax return for the year in which the covered injury was sustained,
if you had dependents.



Gather documentation of the amount of benefits paid or payable (if available), on
your behalf by third-party payers for loss of employment income, disability, and/or
retirement benefits (e.g., disability insurance or Worker’s Compensation).



Submit all of the documents described above to the CICP.

Please fill out your Certifications of Status (Attachments 2 and 3) and send the Certifications and
all the documents that apply to you, to the address below. All materials must be received within
60 days of the date of the enclosed letter. Please inform the Program if you need more time. If
you have any questions, please contact Ana Balingit-Wines at 301-443-2030 or write a letter to
her at the address below.
Health Resources and Services Administration
Countermeasures Injury Compensation Program
5600 Fishers Lane, Room 11C-06
Rockville, MD 20857