Benefits Package and Supporting Documentation

ATTACHMENT 1 OMB Number: 0915-0334

Expiration date: (04/30/2026)

Countermeasures Injury Compensation Program (CICP)

Documentation Required to Reimburse or Pay for Medical Expenses and/or

Lost Employment Income

To calculate the benefits for payment or reimbursement for medical services or items 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 any 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, below, and submit the requested documents described in that section.

1. 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.

2. If you ARE requesting payment or reimbursement for unreimbursed medical expenses related to the covered injury and there is NO third-party payer who has paid or is obligated to pay for these expenses (e.g., 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 list the services or items provided, the amount that was paid, and the amount that may still be owed.

• If you are seeking payments for medical services or items resulting from a covered injury or its health complications expected to be provided in the future, you must submit a statement from each healthcare provider describing those services and items that appear likely to be needed to diagnose or treat the covered injury, or to diagnose, treat, or prevent its health complications, in the future. You must submit documentation, if available, concerning the likely cost of, and the amount expected to be covered by third-party payers for, such services or items.

• Submit all documents described above to the CICP.

3. If you are requesting payment or reimbursement for unreimbursed medical expenses and there IS a third-party payer who has paid or is obligated to pay for all or part of your medical expenses related to the covered 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 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 list the services or items provided, the amount that was paid, and the amount that may still be owed.

• 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 the amount that you are required to pay to satisfy the bill.
  
  

• If you are seeking payments for medical services or items resulting from a covered injury or its health complications expected to be provided in the future, you must submit a statement from each healthcare provider describing those services and items that appear likely to be needed to diagnose or treat the covered injury, or to diagnose, treat, or prevent its health complications, in the future. You must submit documentation, if available, concerning the likely cost of, and the amount expected to be covered by third-party payers for, such services or items.

• Submit all of the documents described above to the CICP.

Section II. Lost Employment Income

Choose either A, B, or C, below, and submit the requested documents described in that section.

1. 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.

2. If you are requesting payment or reimbursement for lost employment income related to the covered injury and there is NOT a third-party payer who has paid or is obligated to pay 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 there is lost employment income (e.g., a timesheet from the pay period(s) showing workdays missed) and documentation of unpaid leave status.

• Gather your Federal tax return or pay stub(s) from all employers showing the 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 the injured countermeasure recipient had dependents.

• Submit all documents described above to the CICP.

3. If you are requesting payment or reimbursement for lost employment income related to the covered injury and there IS a third-party payer who has paid or is obligated to pay for 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 that have paid or may be obligated to pay lost employment income benefits including, but not limited to, disability insurance or Workers’ Compensation. This list must include the address, phone number, and case 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 indicating the number of days (including partial days) of work missed as a result of the covered injury or its health complications for which there is lost income (e.g., a timesheet from the pay period(s) showing workdays missed) and documentation of unpaid leave status.

• Gather your Federal tax return or pay stub(s) from all employers showing the 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 the injured countermeasure recipient 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 Workers’ Compensation).

• Submit all documents described above to the CICP.

Please fill out your Certifications of Status (Attachments 2 and 3). The Program requests that you send all documentation within 60 calendar days of the date of this letter. Please inform the CICP if you need more time. Please submit the requested forms online at injurycompensation.hrsa.gov (preferred). If you cannot submit the documentation electronically, please send the Certifications of Status and the required documentation to the address below:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, Room 8W-25A

Rockville, MD 20857

If you have questions, please call 1-855-266-2427, email [email protected], or mail them to the address above.