Exhibits Finals

OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
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. Then, please
print your name and address and sign in the block in Section 2. Once you have completed and signed this
authorization, please make a copy of your signed form and maintain it with your personal records.
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 World Trade
Center (WTC) Health Program administered by the National Institute for Occupational Safety and
Health (NIOSH)1 for purposes of evaluating your claim for compensation to the VCF. By signing
this document, you also give permission to the VCF to disclose your health information to the
WTC Health Program and to the WTC Health Program to disclose your health information to the
VCF for the purpose of evaluating your claim for compensation under the VCF.
Please note that you may revoke this Authorization at any time, except to the extent that the VCF, WTC
Health Program, or 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 at
2
the bottom of page 3 of this form. 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 decision to sign or not sign this
authorization also has no impact on your eligibility for enrollment, monitoring, treatment, or other WTC
Health Program benefits.
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 and DOJ 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.3 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 by your health care providers (or other entities listed below) 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. Your health care
1

For the purposes of this document, all references to the WTC Health Program also include NIOSH to the
extent it administers the WTC Health Program.
2
If you wish to revoke this authorization because you do not want the VCF and WTC Health Program to
exchange your health information for purposes of evaluating your claim for compensation under the VCF,
then you only need to write to the VCF.
3
The WTC Health Program will protect your health information pursuant to HIPAA and/or any other
relevant laws and regulations.

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OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
Exhibit A to the Eligibility Form For Personal Injury Claimants
Authorization for Release of Medical Records
providers and/or the VCF may also disclose this information to the WTC Health Program for the purpose of
evaluating your claim for benefits under the VCF. In addition, the WTC Health Program may disclose
information to the VCF for purposes of evaluating your VCF claim. This information includes, but is not limited
to, whether you are a member of the WTC Health Program, and if so, where you receive your WTC Health
Program health care benefits; whether you have been certified for treatment under the WTC Health Program;
the number of and specific conditions for which you have been certified for treatment under the WTC Health
Program; and information relating to payment of claims for treatment and pharmaceuticals received under the
WTC Health Program.
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.
By initialing, I acknowledge that the information described above may include mental health
information and I authorize the release of such information.

Initial here:

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 continued

Suite Number

City

(
State/Province

Zip/Postal Code

)

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Telephone Number

Email Address

3791579933
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OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
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 continued

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)

(

)

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Telephone Number (Mobile)

Email Address

This information shall be sent to:
September 11th Victim Compensation Fund
P.O. Box 34500
Washington, DC 20043

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OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
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, including disclosure of information by the WTC Health
Program to the VCF, for the purposes of evaluating my claim for compensation under the VCF. 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)

Print Name

/

Date (mm/dd/yyyy)

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.

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OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
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 from HIPAA and
Non-HIPAA Entities

Patient Name

Date of Birth

Social Security Number

Patient Address

I, or my authorized representative, request that pension and health information 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 provider, pension fund
or other entity 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).

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OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
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 from HIPAA and
Non-HIPAA Entities

7. Name and address of health provider, pension fund, or other entity to release this information:
Please indicate all.

●

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:
September 11th Victim Compensation Fund
P.O. Box 34500
Washington, DC 20043
Overnight deliveries can be made to:
September 11th Victim Compensation Fund
Claims Processing Center
1100 L Street N.W. - Suite 3000
Washington, DC 20005

2303064693
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OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
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 from HIPAA and
Non-HIPAA Entities

9(a). Specific information to be released:
Include: (Indicate by Initialing)

●

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.
Authorization to Discuss Health or Pension Information
9(b).

●

By initialing here

Alcohol/Drug Treatment
Mental Health Information
HIV Related Information

, I authorize
(Initials)

The individuals and entities identified in Question #7
(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:
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:
At request of individual

● Other: To evaluate my claim
for compensation with the September
11th Victim Compensation Fund
12. If not the claimant, name of person signing
form:

11. Date or event on which this authorization will
expire:
Six (6) years from the date of signature or upon
my written termination

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
* 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.

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OMB 1105-0092

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Claimant's SSN or National ID Number

September 11th Victim Compensation Fund
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

day of

, 201

.

Signature of Attorney

Attorney's Name

Attorney's Firm/Address

Attorney's Firm/Address continued

Suite

City

State

Zip/Postal code

5870628680
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Compensation Form Exhibit 1
Social Security Administration Consent for Release of Information
and
Request for Social Security Earnings Information
th

The September 11 Victim Compensation Fund (VCF) will contact the Social Security Administration
(SSA) directly to request information that is pertinent to determining your VCF compensation award. In
order to request the information from the SSA, this cover page and the two (2) attached forms must be
completed, signed, and returned to the VCF. Please carefully follow the instructions below when
completing these forms.
Step 1: Write the Claimant or Decedent Name, VCF Claim Number, and Social Security Number in the
designated spaces at the bottom of this page.
Step 2: Review the two-page “Social Security Administration Consent for Release of Information” form.
To make it easier for you to complete this form, the VCF has already completed many of the
required sections. Please fill in the following information on Page 2 of the form:
• Write the Claimant’s or Decedent’s Name, Date of Birth, and Social Security Number in the
spaces at the top of the page.
• Complete the section at the bottom of the page by signing, dating, and providing your
daytime phone number.
• If you are not the Claimant (i.e., if you are completing this form as the Personal
Representative of a Decedent or as the Authorized Representative of an injured Claimant),
please indicate your relationship to the Claimant in the “Relationship” field.
Step 3: Review the four-page “Request for Social Security Earnings Information” form. To make it easier
for you to complete this form, the VCF has already completed many of the required sections and
has marked certain sections as “Not Applicable”. Please fill in the following information on Page 2
of the form:
• Section 1: Write the Claimant’s or Decedent’s Name, Social Security Number, Other
Name(s) Used (if applicable), and Date of Birth in the spaces provided.
• Section 4: Sign, date, and write your daytime phone number.
You do not need to complete any other parts of this form.
Step 4: Upload this page and both signed SSA forms in their entirety to your online claim and select
“Exhibit 1: Social Security Administration Form” as the document type. If you filed a hard copy
claim, mail the forms to:
th

September 11 Victim Compensation Fund
PO Box 34500
Washington, DC 20043

Please do NOT send these forms directly to the Social Security Administration.
Doing so may delay the processing of your VCF claim.

Claimant or Decedent Full Name: _________________________________________
VCF Claim Number: VCF __ __ __ __ __ __ __
Claimant or Decedent Social Security Number: _____________________________
P.O. Box 34500, Washington, D.C. 20043