SMALLPOX VACCINE INJURY COMPENSATION PROGRAM
REQUEST FORM
INSTRUCTIONS
A complete Request Package consists of a completed and signed Request Form and the required documentation. However, a request for benefits will be considered timely filed as long as a completed and signed Request Form is postmarked within the period described in the regulations, included in these instructions in the paragraph entitled Filing Deadlines.
For the purposes of the Smallpox Vaccine Injury Compensation (SVIC) Program, a Smallpox Vaccine Recipient is defined as:
a health care worker, law enforcement officer, firefighter, security personnel, emergency medical personnel, other public safety personnel, or support personnel for such occupational specialties who has volunteered and been selected to be a member of a smallpox emergency response plan prior to the time at which the Secretary publicly announces that an active case of smallpox has been identified within or outside of the United States;
who is or will be functioning in a role identified in an HHS-approved smallpox emergency response plan (a Plan);
to whom a smallpox vaccine is administered pursuant to a Plan during the effective period of the Declaration.*
A Vaccinia Contact is defined as:
someone who contracted vaccinia during the effective period of the Declaration* (or within 30 days after the end of such period);
prior to contracting vaccinia, was accidentally inoculated by a smallpox vaccine recipient or a contact of such a person.
A Covered Injury is defined as an injury that the Secretary determines:
meets the requirements of the Table (which is presumed to be the direct result of the administration of a smallpox vaccine or accidental vaccinia inoculation); or
was more likely than not, the direct result of:
the administration of a covered countermeasure (including the smallpox vaccine) during the effective period of the Declaration*, in the case of a smallpox vaccine recipient; or
(B) vaccinia contracted through accidental vaccinia inoculation (and not the result of receiving a smallpox vaccine) during the effective period of the Declaration* (or within 30 days after the end of such period), in the case of a vaccinia contact.
An injured smallpox vaccine recipient is defined as a smallpox vaccine recipient who sustained a covered injury. An injured vaccinia contact is defined as a vaccinia contact who sustained a covered injury.
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*Under the Secretary’s Declaration, published in the Federal Register on January 28, 2003, this period is from January 24, 2003 through January 23, 2004.
For a list of required documentation for eligibility determinations, see Attachment 1 below. For a list of the benefits documentation under the SVIC Program, see Attachment 2 below.
FILING DEADLINES
A Request Form concerning an injured smallpox vaccine recipient must be postmarked within 1 year of his or her receiving a smallpox vaccination under a Plan.
A Request Form concerning an injured vaccinia contact must be postmarked within 2 years of the date of the onset of his or her medical injury.
GENERAL INSTRUCTIONS FOR ALL REQUESTERS
Complete the relevant sections of the Request Form. All requesters must complete Section A of the Request Form, which requires information regarding the individual who was medically injured, either as a smallpox vaccine recipient or as a vaccinia contact, and Section E, the Request Form signature section. All information that you submit will be maintained and protected in accordance with the Privacy Act.
Consult the Documentation Checklist for the category of eligibility that best describes you. Then provide the required documentation listed with your category to support your Request Form. A requester is not required to submit any documentation pertaining to benefits until the Secretary has informed the requester that he or she is eligible under the Program.
C. You can submit a Request Package, which includes the Request Form and all the required documentation, to the SVIC Program by U.S. mail, by a private courier service or commercial carrier. Use one of the two addresses specified below.
For U.S. mail only: Smallpox Vaccine Injury Compensation Program Office
5600 Fishers Lane, Room 16C-17
Rockville, MD 20857
For private courier service or commercial carrier only:
Smallpox Vaccine Injury Compensation Program Office
5600 Fishers Lane, 10th Floor
Rockville, MD 20857
A separate Request Form must be submitted for each medically injured person who may be eligible for benefits payment (i.e., a smallpox vaccine recipient or a vaccinia contact).
Multiple survivors may submit one Request Form for the death benefit (e.g., the surviving children and spouse, or surviving children if there is no surviving spouse). Survivors may also submit separate Request Forms.
Keep a copy of all forms and documentation that you submitted for your own records.
CHANGES IN INFORMATION PROVIDED
Should there be a change in the information you provided with your Request Form or in your documentation, you are required to notify in writing the SVIC Program Office at either of the addresses above. Please note that if you fail to provide the Program with this information, the Program may not be able to contact you regarding the processing of your Request Package.
REQUEST FORM INSTRUCTIONS
SECTION A Instructions
This section is required for all requesters
This section describes an injured smallpox vaccine recipient or vaccinia contact. If a Request Form is filed on behalf of an injured smallpox vaccine recipient, complete A1. If a Request Form is filed on behalf of an injured vaccinia contact, complete A2.
Section A1 describes an injured smallpox vaccine recipient.
Name: The full name of the smallpox vaccine recipient.
Social Security Number: That individual’s 9-digit Social Security Number.
Date of Birth: That individual’s date of birth (month, day, and year).
Type of injury from the vaccination or other covered countermeasure: A brief description of the medical injury (e.g., scarring, Stevens-Johnson Syndrome, etc.).
The number of days of lost employment income resulting from the medical injury: Enter the number of days away from work caused by the medical injury and its health complications for which he or she lost employment income. If the individual lost partial days (e.g., half of a work day), compute the number of partial days that total a complete workday, and enter the number.
Check here [ ] if the smallpox vaccine recipient had a dependent under the age of 18 at the date of the onset of medical injury. Whether an individual had at least one dependent (as defined by the Internal Revenue Service) under the age of 18 at the time of the covered injury affects the available amount of benefit for lost employment income.
If the smallpox vaccine recipient is no longer living, provide the date of death: The smallpox vaccine recipient’s date of death, if applicable (month, day, and year).
If the smallpox vaccine recipient is still living:
Address: That individual’s current home address.
City: That individual’s current city of residence.
State: That individual’s current state of residence.
Zip Code: The 5 or 9 digit zip code for that individual’s current residence.
Daytime telephone number(s): That individual’s telephone number(s), including the area code, where he or she can be reached during business hours.
Section A2 describes an injured vaccinia contact.
Name: The full name of the injured vaccinia contact.
Social Security Number: That individual’s 9-digit Social Security Number.
Date of Birth: That individual’s date of birth (month, day, and year).
Type of injury from the vaccinia: A brief description of the medical injury (e.g., scarring, encephalopathy, etc.).
The number of days of lost employment income resulting from the medical injury: Enter the number of days away from work caused by the medical injury and its health complications for which he or she lost employment income. If the individual lost partial days (e.g., half of a work day), compute the number of partial days that total a complete workday, and enter the number.
Check here [ ] if the smallpox vaccine recipient had a dependent under the age of 18 at the date of the onset of injury. Whether an individual had at least one dependent (as defined by the Internal Revenue Service) under the age of 18 at the time of the covered injury affects the available amount of benefit for lost employment income.
If the vaccinia contact is no longer living, provide the date of death: The vaccinia contact’s date of death, if applicable (month, day, and year).
If the vaccinia contact is living:
Address: That individual’s current home address.
City: That individual’s current city of residence.
State: That individual’s current state of residence.
Zip Code: The 5 or 9 digit zip code of that individual’s current residence.
Daytime telephone number(s): That individual’s telephone number(s), including the area code, where he or she can be reached during business hours.
Source of Exposure to Vaccinia. The requester must indicate if the injured vaccinia contact contracted vaccinia from a smallpox vaccine recipient or a vaccinia contact. If the vaccinia contact’s source of exposure is unknown, the requester must explain the circumstances by which the contact contracted vaccinia.
Check the first box if the source of vaccinia was a smallpox vaccine recipient. Enter the smallpox vaccinia recipient’s name in the line provided.
Check the second box if the source of vaccinia was person who contracted vaccinia from a smallpox vaccine recipient. Enter the names of the vaccinia contact and the smallpox vaccine recipient in the places provided.
Check the third box if the source of vaccinia is unknown, and explain the source of the vaccinia exposure. Attach a separate sheet describing the circumstances surrounding the accidental vaccinia exposure that led to the contracting of vaccinia. Be as specific as possible.
SECTION B Instructions
Complete this section if you are filing a Request Form as a survivor of a smallpox vaccine recipient or a vaccinia contact.
This section describes the survivors of a deceased smallpox vaccine recipient or vaccinia contact who died as a direct result of a covered injury. The following is the list of individuals who may be eligible for benefits:
A surviving spouse.
Child(ren) - the definition of “surviving eligible child” includes: an individual who is a natural, illegitimate, adopted, or posthumous child, or stepchild, of the deceased person, and is 18 years of age or younger, or between 19 and 23 years of age and a full-time student, or is over 18 years of age and incapable of self-support because of physical or mental disability.
Dependent(s) (as defined by the IRS) younger than 18 years of age.
Beneficiary in the most recently executed life insurance policy and there are no survivors described above.
Parent(s) and there are no survivors described above.
Legal guardian of a deceased minor, and there are no survivors described above.
(Note: If there are minor children under the age of 18 who were dependents of the deceased, the legal guardian has the option to select the method of payment of death benefits. See Section D Instructions for details).
Name: The survivor’s full name.
Social Security Number: The survivor’s 9-digit Social Security Number.
Date of Birth: The survivor’s date of birth (month, day, and year).
Address: The survivor’s current home address.
City: The survivor’s current city of residence.
State: The survivor’s current state of residence.
Zip Code: 5 or 9 digit zip code of the survivor’s current residence.
Daytime telephone number(s): The survivor’s telephone number(s), including the area code, where he or she can be reached during business hours.
Check the box that describes the Survivor’s Relationship to the individual in Section A. Check the box that best describes the survivor’s relationship to the deceased individual.
Check the box that indicates if the survivor is a sole survivor or if there are other survivors who may be eligible for benefits payment. If you are the only eligible survivor, check the first box. If there are other survivors, then list all the other survivors in the categories listed above on the Request Form and identify their relationship to the deceased. If you need more space, append the Request Form with another page and list all of them.
Check the box if this is a Request Form filed by multiple survivors and attach another page listing all the survivors’ names, Social Security Numbers, dates of birth, complete addresses, and daytime telephone numbers.
SECTION C Instructions
Complete this section if you are the representative of the estate of a deceased smallpox vaccine recipient or vaccinia contact.
Name: The estate representative’s full name.
Address: The estate representative’s current home or office address.
City: The city associated with that address.
State: The state associated with that address.
Zip Code: 5 or 9 digit zip code associated with that address.
Daytime telephone number(s): The estate representative’s telephone number(s), including the area code, where he or she can be reached during business hours.
SECTION D Instructions
Complete this section if you are a personal representative acting on behalf of a requester.
This section describes an attorney or other representative, if any, for the requester. If this section is completed, all communications related to the Request Package will only occur with the personal representative.
Name: The personal representative’s full name.
Address: The personal representative’s current home or office address.
City: The city associated with that address.
State: The state associated with that address.
Zip Code: 5 or 9 digit zip code associated with that address.
Daytime telephone number(s): The personal representative’s telephone number(s), including the area code, where he or she can be reached during business hours.
Does the person you are representing have the legal capacity to receive benefits? If the requester is of the age of majority and has the legal capacity to receive a benefit, check the first box. If the requester is a minor or has been declared legally incompetent by a court, then check the second box and explain why this option was chosen (e.g., the person is a minor).
The SVIC Program pays death benefits under two different calculations: the Standard Calculation and the Alternative Calculation.
The Standard Calculation is based on the U.S. Department of Justice’s Public Safety Officers’ Benefit (PSOB) Program. This is the only method of payment for a surviving spouse, beneficiary in the most recently executed life insurance policy, parent, and surviving legal guardian of a deceased eligible individual under the age of 18. This is also the only method of payment for a surviving eligible child who is not the dependent of the deceased person.
The Alternative Calculation uses a formula based on the income of the deceased smallpox vaccine recipient or vaccinia contact and the age of that person’s youngest dependent under the age of 18. This is the only method of payment for a dependent under the age of 18 of a deceased smallpox vaccine recipient or vaccinia contact who is not that person’s child (e.g., a niece or nephew dependent).
The legal guardian of a dependent under the age of 18 who is a surviving child has the option to select either the Standard Calculation or the Alternative Calculation. Use the space on the Request Form to check the box for Death Benefit under the Standard Calculation or Death Benefit under the Alternative Calculation.
For a complete description of the death benefits, see Attachment 2 at the end of the Request Form Instructions.
SECTION E Instructions
Only requesters or their legal guardians complete this section.
All requesters must sign the Request Form, unless the requester does not have the legal capacity to receive payments under the Act. In that case, a legal guardian must sign for the individual. If multiple survivors are filing jointly, at least one of these survivors must sign the Request Form.
Name (type or print clearly): The name of the person signing the Request Form, presented legibly.
Signature: An original signature in ink.
Date: Date Request Form was signed (month, day, and year).
By signing section E, the requester (or the requester’s legal guardian) is attesting under penalty of prosecution that all statements in the Request Form are true and accurate to the best of his or her knowledge. In addition, the requester is also certifying that any documentation submitted, either with the Request Form or subsequent to it, is held to the same standard of accuracy as the Request Form, and with the same penalty of prosecution for fraud. If the requester has used a legal or personal representative to submit the Request Form and documentation, the requester’s signature also authorizes the personal representative identified in Section D to interact with the SVIC Program on his or her behalf.
In addition, the requester is also certifying that any documentation submitted, either with the Request Form or subsequent to it, is held to the same standard of accuracy as the Request Form, and that false statements or submissions in such documentation are subject to the same penalty of prosecution for fraud or other violations of the law.
If the requester has used a legal or personal representative to submit the Request Form and documentation, the requester's signature also authorizes the personal representative identified in Section D to interact with the SVIC Program on his or her behalf.
SMALLPOX VACCINE INJURY COMPENSATION PROGRAM
REQUEST PACKAGE
DOCUMENTATION CHECKLIST
The Documentation Checklist is a listing of the eligibility and benefits documentation, by category of requester, that is to be submitted to the Smallpox Vaccine Injury Compensation (SVIC) Program. Copies of documentation may be provided in lieu of originals.
In order to meet the filing deadlines as described in the Request Form Instructions, a requester need only submit a completed and signed Request Form. However, in order for the Secretary to determine if the requester is eligible for benefits under the Smallpox Emergency Personnel Protection Act of 2003 (the Act), the Secretary must receive the eligibility documentation.
After the Secretary has determined that a requester is eligible for benefits under the Act, then the benefits documentation must be submitted in order for the Secretary to determine the type and amount of benefits.
Contents
Section A. Smallpox Vaccine Recipient or Vaccinia Contact who sustained a covered injury
A1. Smallpox Vaccine Recipient
A2. Vaccinia Contact
Section
B. Survivor(s)
Spouse
Child(ren)
Dependent(s) under the age of 18
Beneficiary of the most recent life insurance policy
Parent(s)
Legal guardian(s) of a deceased, eligible minor
Section C. Representative(s) of the Estate
Section
D. Personal Representative
Section E. Signature
Attachment 1. Description of Eligibility Documentation
Attachment 2. Description of Benefits Documentation
Attachment 3. Description of the Calculation of Benefits
A. INDIVIDUALS WHO SUSTAINED A COVERED INJURY
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Category of Eligibility |
Required Documentation |
A1. SMALLPOX VACCINE RECIPIENT A smallpox vaccine recipient may be eligible for medical benefits, lost employment income benefits, or both. |
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[ ] The individual who
(For the full definition of a smallpox vaccine recipient, see the first page of the Request Form Instructions).
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I. Eligibility documentation
1. Smallpox Vaccine Injury Compensation Program Certification Form (or other documentation that the individual received a smallpox vaccination under a Plan); and
2. Medical documentation showing that the smallpox vaccine recipient: (a) Received a smallpox vaccination; and (b) Suffered a medical injury resulting from the smallpox vaccine or another covered countermeasure (e.g., cidofovir or vaccinia immune globulin). Include all related medical records.
II. Benefits documentation
(a) Past and current medical expenses. (b) Potential future medical expenses. (c) A list of all third-party payors (e.g. insurance company) that have paid or possibly will pay for medical services and items to the smallpox vaccine recipient.
2. Lost employment income benefits: (a) Documentation of number of days (including partial days) of lost employment income. (b) Gross earned employment income at the time of the covered injury. (c) A list of all third-party payors (e.g., Worker’s Compensation) that have or will provide benefits for loss of employment income or disability or retirement benefits. (d) Any documentation of compensation by any of those third-party payors. (e) If applicable, documentation that the individual has as least one dependent under the age of 18 years (e.g. IRS Form 1040). |
Category of Eligibility |
Required Documentation |
A2. VACCINIA CONTACT A vaccinia contact may be eligible for medical benefits, lost employment income benefits, or both. |
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[ ] The individual who was exposed to vaccinia by either a smallpox vaccine recipient or another vaccinia contact who contracted vaccinia from a smallpox vaccine recipient. |
I. Eligibility documentation
1. Smallpox Vaccine Injury Compensation Program Certification Form that identifies the smallpox vaccine recipient who was the source of the vaccinia exposure (or other documentation that the individual received a smallpox vaccination under a Plan).
2. Medical documentation showing that the vaccinia contact suffered a medical injury resulting from the vaccinia, and the date that the vaccinia contact contracted vaccinai. Include all related medical records.
II. Benefits documentation
1.Medical benefits: (a) Past and current medical expenses. (b) Potential future medical expenses. (c) A list of all third-party payors (e.g. insurance company) that have paid or possibly will pay for medical services and items to the vaccinia contact.
2. Lost employment income benefits: (a) Documentation of number of days (including partial days) of lost employment income. (b) Gross earned employment income at the time of the covered injury. (c) A list of all third-party payors (e.g., Worker’s Compensation) who have provided or will provide benefits for loss of employment income or disability retirement benefits. (d) Any documentation of compensation by any of the those third-party payors. (e) If applicable, documentation that the individual has at least one dependent under the age of 18 years (e.g., IRS Form 1040).
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B. SURVIVORS OF A SMALLPOX VACCINE RECIPIENT OR A VACCINIA CONTACT Survivors are eligible for death benefits only. |
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Surviving spouse of an individual who died as a direct result of a covered injury.
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I. Eligibility documentation
1. All eligibility documentation required for the smallpox vaccine recipient (see A1 above in the Documentation Checklist) or who was a vaccinia contact (see A2 above in the Documentation Checklist).
2. Medical documentation that the individual you survived died as a direct result of a covered injury.
3. Legal documentation: (a) A death certificate for the individual you survived who died as a direct result of a covered injury. If a death certificate is not available, other documentation of that individual’s death; and (b) A marriage certificate or other proof of lawful marriage, which shows that you were the spouse of the individual at the time of that individual’s death.
(a) Public Safety Officers’ Benefits (PSOB) Program death benefit, if applicable. (b) PSOB Program disability benefit, if applicable.
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Surviving child or children of an individual who died as a direct result of a covered injury. For the purpose of the SVIC Program, an eligible child is :
(Note: an eligible child’s Request Form must be submitted by a personal representative. See Section D of the Documentation Checklist). |
I. Eligibility documentation
1. All eligibility documentation required for the smallpox vaccine recipient (see A1 above in the Documentation Checklist) or who was a vaccinia contact (see A2 above in the Documentation Checklist).
2. Medical documentation that the individual died as a direct result of a covered injury.
3. Legal documentation (a) A death certificate for the individual the child survived who died as a direct result of a covered injury. If a death certificate is not available, other documentation of that individual’s death; and (b) A birth certificate of the child for age verification. If the birth certificate does not identify the deceased as the child’s parent, other documentation that shows that the child had a child/parent relation with the individual he or she survived.
II . Benefits documentation (a) Selection of method of payment, either Standard Calculation of Alternative Calculation (this is on the Request Form). (b) if Standard Calculation is selected, (i) Public Safety Officers’ Benefits (PSOB) Program death benefit, if applicable. (ii) PSOB Program disability benefit, if applicable. (c) if Alternative Calculation is selected, see Attachment 2 for the list.
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Surviving dependent (e.g. niece, nephew, or grandchild, etc.) under the age of 18 of an individual who died as a direct result of a covered injury.
(Note: Request Form on behalf of a surviving dependent under the age of 18 must be submitted by a personal representative. See Section D of the Documentation Checklist). |
I. Eligibility documentation
1. All eligibility documentation required for the smallpox vaccine recipient (see A1 above in the Documentation Checklist) or who was a vaccinia contact (see A2 above in the Documentation Checklist).
2. Medical documentation that the individual the dependent survived died as a direct result of a covered injury.
3. Legal documentation (a) A death certificate for the individual the dependent survived who died as a direct result of a covered injury. If a death certificate is not available, other documentation of that individual’s death; and (b) Documentation that shows that the requester was the dependent of the individual at the time of that individual’s death. (c) The dependent’s birth certificate.
(a) Selection of method of payment, either Standard Calculation of Alternative Calculation (this is on the Request Form). (b) if Standard Calculation is selected, (i) Public Safety Officers’ Benefits (PSOB) Program death benefit, if applicable. (ii) PSOB Program disability benefit, if applicable. (c) if Alternative Calculation is selected, see Attachment 2 for the list. (Note: a surviving dependent who is not the child of an individual who died as a direct result of a covered injury can only be paid under the Alternative Calculation).
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Surviving individual who is the beneficiary in the most recent life insurance policy of the individual who died as a direct result of a covered injury.
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I. Eligibility documentation
1. All eligibility documentation required for the smallpox vaccine recipient (see A1 above in the Documentation Checklist) or who was a vaccinia contact (see A2 above in the Documentation Checklist).
2. Medical documentation that the individual died as a direct result of a covered injury.
3. Legal documentation (a) A death certificate for the individual who died as a direct result of a covered injury. If a death certificate is not available, other documentation of that individual’s death; and (b) A copy of the deceased individual’s most recent life insurance policy naming you as the beneficiary.
II. Benefits documentation (a) Public Safety Officers’ Benefits (PSOB) Program death benefit, if applicable. (b) PSOB Program disability benefit, if applicable.
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Surviving parent or parents of an individual who died as a direct result of a covered injury.
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I. Eligibility documentation
1. All eligibility documentation required for the smallpox vaccine recipient (see A1 above in the Documentation Checklist) or who was a vaccinia contact (see A2 above in the Documentation Checklist).
2. Medical documentation that the individual died as a direct result of a covered injury.
3. Legal documentation (a) A death certificate for the individual who died as a direct result of a covered injury. If a death certificate is not available, other documentation of that individual’s death; and (b) A birth certificate of the deceased individual that shows that you were the parent(s). If the birth certificate does not establish you a parent, other documentation of the parent/child relationship.
II. Benefits documentation (a) Public Safety Officers’ Benefits (PSOB) Program death benefit, if applicable. (b) PSOB Program disability benefit, if applicable.
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Legal guardian (e.g. grandparent) of deceased, eligible minor. |
I. Eligibility documentation
1. All eligibility documentation required for the smallpox vaccine recipient (see A1 above in the Documentation Checklist) or who was a vaccinia contact (see A2 above in the Documentation Checklist).
2. Medical documentation that the individual died as a direct result of a covered injury.
3. Legal documentation (a) A death certificate for the individual who died as a direct result of a covered injury. If a death certificate is not available, other documentation of that individual’s death; and (b) Documentation that establishes the legal guardianship.
II. Benefits documentation (a) Public Safety Officers’ Benefits (PSOB) Program death benefit, if applicable. (b) PSOB Program disability benefit, if applicable.
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C. PERSONAL REPRESENTATIVES OF ESTATES OF SMALLPOX VACCINE RECIPIENTS OR VACCINIA CONTACTS. |
The estates may be eligible for medical benefits and/or lost employment income benefits that would have been paid to a deceased, injured smallpox vaccine recipient or deceased, injured vaccinia contact.
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Representative of the estate of deceased smallpox vaccine recipients or vaccinia contacts who died prior to receiving full benefit by the SVIC Program.
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I. Eligibility documentation
1. All of the eligibility documentation required of individual whose estate you represent (see Section A1 or Section A2 above in the Documentation Checklist).
2. Legal documentation (a) A death certificate for the eligible individual, or other documentation of that individual’s death; and (b) The deceased individual’s will or other documentation that you represent the estate of the deceased individual.
II. Benefits Documentation All of the benefits documentation required of the individual whose estate you represent (see Section A1 or Section A2 above in the Documentation Checklist).
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D. PERSONAL REPRESENTATIVES |
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Personal Representatives: Personal representatives may act on behalf of any individual who may be eligible to receive payment under the Act. 1)
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In all cases, the personal representative must submit all documentation required for the eligible individual.
In those cases in which the eligible individual does not have the legal capacity to receive payment under the Act, a personal representative may receive payment for a legally incompetent individual by submitting the following written documentation:
(1) Proof showing the eligible individual does not have the legal capacity to receive payment under the Act (e.g., a birth certificate showing that the eligible individual is a minor or other documentation showing that the eligible individual is legally incompetent); and (2) For legal guardians, documentation showing that you have the authority to receive payment for the eligible individual (e.g., proof of legal guardianship, or, if the legal guardian is a parent, the birth certificate). |
ATTACHMENT 1
DESCRIPTION OF ELIGIBILITY DOCUMENTATION
A smallpox vaccine recipient must receive the smallpox vaccine under a Plan during the period of the Secretary’s Declaration (January 24, 2003 through January 23, 2004, subject to change). The Request Form must be submitted within 1 year of the smallpox vaccination.
A vaccinia contact must document the medical injury during the period of the Secretary’s Declaration or no later then three months after the end of the Declaration Period. The Request Form must be submitted within two years of the first symptom.
The following is a description of the documentation that requesters must submit to the Smallpox Vaccine Injury Compensation (SVIC) Program in order for the Secretary to determine eligibility.
1. Certification documentation.
In addition to the Request Form, the SVIC Program requires documentation demonstrating that the smallpox vaccine recipient identified in a Request Form:
is a health care worker, law enforcement officer, firefighter, security personal, emergency medical personal, other public safety personal, or support personal for such occupational specialties who has volunteered and been selected to be a member of a smallpox emergency response plan prior to the time at which the Secretary publicly announces that an active case of smallpox has been identified within or outside of the United States and that the requester is or will be functioning in a role identified in a smallpox emergency response plan; and
was administered a smallpox vaccine pursuant to an approved smallpox emergency response plan during the effective period of the Declaration.
Requesters may use the Certification Form developed for the Program, available from the SVIC Program Office.
2. Medical records necessary to establish that a covered injury was sustained.
In order to establish that a smallpox vaccine recipient or vaccinia contact sustained a
covered injury, a requester must submit the following medical records:
all physician, clinic, or hospital outpatient medical records documenting medical visits, consultations, and test results that occurred on or after the date of the smallpox vaccination or exposure to vaccinia; and
all inpatient hospital medical records, including the admission history and physical examination, the discharge summary, all physician subspecialty consultation reports, all progress notes, and all test results that occurred on or after the date of the smallpox vaccination or exposure to vaccinia.
If the smallpox vaccine recipient’s injury relates to the administration of cidofovir or its derivatives or Vaccinia Immune Globulin (VIG), and not the smallpox vaccine, documentation demonstrating that the requester was administered such a covered countermeasure during the effective period of the Declaration.
A requester may submit additional medical documentation that he or she believes will support the Request Package. Although generally not required if a Table injury was sustained, a requester may need to introduce additional medical documentation or scientific documentation in order to establish that an injury was caused by a covered countermeasure (including the smallpox vaccine) or vaccinia contracted through accidental vaccinia inoculation.
If certain medical records listed above are unavailable to the requester after he or she has made reasonable efforts to obtain the records, the requester must submit a statement describing the reasons for the records= unavailability and the efforts he or she has taken to obtain the records. The Secretary has the discretion to accept such a statement in place of the unavailable medical records. In this circumstance, the Secretary may require an authorization from the requester (or his or her representative) to try to obtain the records on his or her behalf.
In certain circumstances, the Secretary may require additional medical records to make a determination that a covered injury was sustained (e.g., medical records prior to the date of vaccination or accidental vaccinia exposure) or may determine that certain records described above are not necessary for an eligibility determination (e.g., records that are duplicative of other records submitted). If the Program requests additional medical records (or information) from a requester=s health care practitioner, then the requester may use a release form in order to have the medical records sent directly to the Program.
ATTACHMENT 2
DESCRIPTION OF BENEFITS DOCUMENTATION
1. Documentation an eligible requester seeking medical benefits must submit.
A requester deemed eligible by the Secretary who seeks payment or reimbursement for medical services or items must submit the following:
List of Third-party Payors. The requester must submit a list of all third-party payors that may have an obligation to pay for or provide any medical services or items for which payment or reimbursement is being sought under this Program. Such third-party payors may include, but are not limited to, health maintenance organizations, health insurance companies, Medicare, Medicaid, and other entities obligated to provide medical services or items or recompense individuals for medical expenses. Such a list must include the individual=s account numbers and other applicable information. If the requester knows of no such third-party payor, he or she must certify to that fact. If the requester becomes aware that a third-party payor may have such an obligation, the requester must inform the Secretary within 10 business days of becoming aware of this information.
Documents for Medical Services or Items Provided in the Past. A
requester seeking payment or reimbursement for medical services or items provided in the past must submit an itemized statement from each health care entity (e.g., clinic, hospital, doctor, or pharmacy) and third-party payor listing the services or items provided to diagnose or treat the covered injury or its health complications and the amounts paid or expected to be paid by third parties for such services or items (e.g., an Explanation of Benefits from the individual=s health insurance company). If no third-party payor has an obligation to pay for or provide such services or items, the requester must certify to that fact and submit an itemized list of the services or items provided (including the total cost of such services or items). To assist the Secretary in making a determination as to whether such services or items were reasonable and necessary to diagnose or treat a covered injury or its health complications, the requester may submit, in addition to the required medical records, documentation showing that a health care practitioner prescribed or recommended such services or items. The medical records must support the requested services and items.
Documents for Medical Services and Items Expected to be Provided in the Future. A requester seeking payments for medical services or items expected to be provided in the future must submit a statement from one or more health care practitioner(s) (e.g., a treating neurologist for neurologic issues and a treating cardiologist for cardiologic issues) describing those services and items that appear likely to be needed to diagnose or treat the covered injury or its health complications in the future. The medical records must support the requested services and items. A requester must submit documentation, if available, concerning the likely cost of, and the amount expected to be paid by third-party payors for, such services or items.
2. Documentation an eligible requester seeking benefits for lost employment income must submit.
A requester deemed eligible by the Secretary who seeks benefits for lost employment income from the Program must submit, in addition to the documentation submitted under subpart F, documentation describing:
The number of days (including partial days) of work missed by the smallpox
vaccine recipient or vaccinia contact as a result of the covered injury or its health complications for which employment income was lost (e.g., time sheet from pay period reflecting work days missed). Days for which an individual used leave in order to be paid for lost work will be considered days of work for which employment income was received (unless the individual=s employer restores the leave that was used by putting the individual in the same position as if he or she had not used leave).
The smallpox vaccine recipient or vaccinia contact=s gross earned employment
income at the time the covered injury was sustained (e.g., the individual=s most recent Federal tax return or a pay stub from the time of the covered injury)
Whether the smallpox vaccine recipient or vaccinia contact had one or more dependents at the time the covered injury was sustained (e.g., the individual=s most recent Federal tax return); and
All third-party payors that have paid for or that may be required to pay the requester benefits for loss of employment income or provide disability and retirement benefits for which payment or reimbursement is being sought under this Program (e.g., State workers= compensation programs, disability insurance programs, etc.). A requester must submit documentation, if available, concerning the amount of such payments or benefits expected to be paid by third-party payors. If the requester knows of no such third-party payor, he or she must certify to that fact. If, at any time, the requester becomes aware that a third-party payor may have such an obligation, the requester must inform the Secretary within 10 business days of becoming aware of this information.
3. Documentation an eligible requester seeking a death benefit must submit.
A requester deemed an eligible survivor by the Secretary who seeks a death
benefit under the Standard Calculation must submit a certification informing the Secretary whether a disability or death benefit was paid under the PSOB Program with respect to the deceased smallpox vaccine recipient or vaccinia contact. If such a benefit(s) was provided, the requester must submit documentation showing the amount of the benefit(s) provided by the PSOB Program. If no such benefits were provided, the certification must explain whether any survivors are eligible for a death benefit under the PSOB Program and, if so, whether death benefits have been sought under the PSOB Program.
A representative seeking a death benefit under the Alternative Calculation on behalf of a dependent requester younger than the age of 18 deemed an eligible survivor by the Secretary must submit the following:
Documentation showing that the deceased smallpox vaccine recipient or vaccinia contact is survived by one or more dependents younger than the age of 18. Such documentation must show the date of birth of all such dependents (e.g., copies of birth certificates);
A written selection on the Request Form by each legal guardian, on behalf of all of the dependents of this section for whom he or she is the legal guardian, to receive proportional death benefits under the Alternative Calculation, in place of proportional benefits available under the Standard Calculation.
Documentation showing that the requester is the legal guardian of all of the dependents. If multiple dependents have different legal guardians, the legal guardian of each dependent(s) must submit such documentation.
Documentation showing the deceased smallpox vaccine recipient or vaccinia contact=s gross earned employment income at the time the covered injury was sustained (e.g., the decedent=s most recent Federal tax return or a pay stub from the time of the covered injury); and
A description of all third-party payors that have paid for or that may be required to pay for the benefits. This description must include the amount of such benefits that have been paid or that may be authorized to be paid in the future. If the representative knows of no such third-party payor, he or she must certify to that fact. If, at any time, the representative becomes aware that a third-party payor may have such an obligation, he or she must inform the Secretary within 10 business days of becoming aware of this information.
ATTACHMENT 3
DESCRIPTION OF THE CALCULATION OF BENEFITS
Eligible requesters may be eligible for medical benefits, lost income benefits, or death benefits. The follow is a description of the calculation of the different kinds of benefits.
I. Calculation of medical benefits.
In calculating medical benefits, the Secretary will take into consideration all reasonable costs for those medical items and services that are reasonable and necessary to diagnose or treat a requester=s covered injury or its health complications. The Secretary will consider and may rely upon benefits documentation submitted by the requester (e.g., bills, Explanation of Benefits, and cost-related documentation to support the expenses relating to the covered injury or its health complications). The Secretary will make such payments only to the extent that such costs were not, and will not be, paid by any third-party payor. There are no caps on medical benefits that may be provided under the Program.
II. Calculation of benefits for lost employment income.
Primary Calculation. Benefits under this section may be paid for days of work lost
as a result of a covered injury or its health complications if the requester lost employment income for the lost work days. A requester=s use of leave (other than disability or retirement benefits) for lost work days will not be considered employment income.
The Secretary will calculate the rate of benefits to be paid based on the requester=s employment income, which includes income from self-employment, at the time he or she sustained the covered injury.
For a requester with no dependents at the time the covered injury was sustained, the benefits are 66 2/3% of the requester=s employment income at the time the covered injury was sustained.
For a requester with one or more dependents at the time the covered injury was sustained, the benefits are 75% of the requester=s employment income at the time the covered injury was sustained; and In the case of a requester who is a minor, the Secretary may pay and calculate the payment of benefits for lost employment income in accordance with the FECA Program.
Adjustment for Consumer Price Index. The benefits for lost employment income paid under the Program will be indexed to the Consumer Price Index on an annual basis.
Limitations on benefits paid. The Secretary will reduce the benefits calculated, according to the following limitations:
Annual Limitation. The maximum amount that a requester can receive in any one
year in benefits for lost employment income under this Program is $50,000
Lifetime Limitation. The maximum amount that a requester can receive during his or her lifetime in benefits for lost employment income under this Program is the amount of death benefits that may be paid to survivors. However, this lifetime cap does not apply in the event that the Secretary determines that the requester has a covered injury (or injuries) meeting the definition of Adisability@ in section 216(i) of the Social Security Act, 42 U.S.C. 416(i); and
Number of Lost Work Days. A requester will be compensated for ten or more days of work lost if he or she lost employment income for those days as a result of the covered injury (or its health complications). If the number of days of lost employment income due to the covered injury (or its health complications) is fewer than ten, the Secretary will reduce the number of lost work days by five days. If the requester lost employment income for a period of 5 days or fewer, no benefits for lost employment income will be paid. Lost work days do not need to be consecutive.
Reductions for other coverage. From the amount of benefits calculated, the Secretary will make reductions:
for all payments made, or expected to be made in the future, to the requester for compensation of lost employment income or disability or retirement benefits, by any third-party payor in relation to the covered injury or its health complications; and
so that the total amount of benefits for lost employment income paid to a requester
under this Program, together with the total amounts paid (or payable) by third-party payors, as described above, do not exceed 66 2/3% (or 75%, if the requester had at least one dependent at the time the covered injury was sustained) of the requester=s employment income at the time of the covered injury. If a requester receives a lump-sum payment from any third-party payor, under any obligation described above, the Secretary shall deem such a payment to be received over a period of years, rather than in a single year. The Secretary has discretion as to how to apportion such payments over multiple years
Termination of Payments. The Secretary will not pay benefits for lost employment
income after the requester reaches the age of 65.
III. Calculation of Death Benefits.
Of all payment methods, this has the most complexities. Variables include the hierarchy of survivors, payments for dependents under the age of 18, eligibility for death benefits under the PSOB, and, in certain cases, the amount of lost employment income benefits that the smallpox vaccine recipient received under the SVIC Program. Therefore, the Program suggests that requesters read this section carefully and refer to the administrative regulations that govern the operations of the Program.
Definitions. For purposes of this section:
deceased individual means an otherwise eligible deceased smallpox vaccine recipient or vaccinia contact; and
dependents means a deceased individual=s surviving eligible dependents younger than 18 years of age (at the time of filing and payment).
A. Standard calculation of death benefits.
The maximum death benefit available is the amount of the comparable death benefit calculated under the PSOB Program in the same fiscal year, except as follows:
If death benefits under the PSOB Program are reduced based on a limitation on appropriations, death benefits will not be similarly reduced; and
The death benefit paid will be reduced by the total amount of benefits for lost employment income paid under this Program to the deceased individual during his or her lifetime.
No death benefit will be paid under this paragraph if a death benefit has been paid, or if survivors are eligible to receive a death benefit, under the PSOB Program with respect to the deceased individual.
No death benefit will be paid if a disability benefit has been paid under the PSOB Program with respect to the deceased individual. However, if the PSOB Program disability benefit paid was reduced because of a limitation on appropriations, a death benefit will be available to the extent necessary to ensure that the total amount of disability benefits paid under the PSOB Program to eligible survivor(s), together with the amount of death benefits, equals the amount of the PSOB death benefit.
Death benefits under the Standard Calculation will be paid a lump sum.
B. Alternative Calculation of death benefits. This option is available to surviving dependents younger than the age of 18. If a deceased smallpox vaccine recipient or vaccinia contact had at least one dependent who is younger than the age of 18, the legal guardian of all such dependents can request benefits under the alternative calculation. To receive such a benefit, the legal guardian(s) of all such dependents, on behalf of all of them, must file an election (included on the Request Form in Section D).
General Information. Payments made under the Alternative Calculation will be made to all of the dependents. Although payments under the Alternative Calculation are based on the deceased individual=s employment income at the time he or she sustained the covered injury, benefits under this paragraph are death benefits and do not represent benefits for lost employment income.
Election. Before a payment will be approved, the legal guardian(s) of the dependents must elect, on behalf of all the dependents, to receive a death benefit under this paragraph. If such an election is approved by the Secretary, these dependents will be paid the death benefit in lieu of the proportionate share of benefits that would otherwise be available to them under the Standard Calculation.
Amount of Payments. The maximum death benefit available under this paragraph is 75% of the deceased individual=s income (including income from self-employment) at the time he or she sustained the covered injury that resulted in death, indexed to the Consumer Price Index on an annual basis, except as follows:
The maximum payment of death benefits that may be made to the aggregate of the dependents in any one year is $50,000.
All payments made under this paragraph will stop once the youngest of the dependents reaches the age of 18.
Reductions for other coverage. The total amount of death benefits will be reduced so that the total amount of payments made (or expected to be made) under obligations described in Attachment 2 under the documentation for Lost Income Benefits, together with the death benefits paid under the Altnerative Calculation, is not greater than the amount of lost employment income payments.
The amount of death benefits will be reduced for all payments made, or expected to be paid in the future, by any third-party payor for:
compensation for the deceased individual=s loss of employment income;
death benefits in relation to the deceased individual (including, but not limited to, death benefits under the PSOB Program); and
disability, retirement, or life insurance benefits on behalf of the dependents (including, but not limited to, disability benefits on behalf of the dependents under the PSOB Program).
In calculating such reductions, the Secretary will deem any lump-sum payment made by a third-party payor under any obligation , as received over a period of years, rather than in a single year. The Secretary has discretion as to how to apportion such payments over multiple years.
Timing of Payments. Payments made under the Alternative Calculation will be made on an annual basis, beginning at the time of the initial payment. In the year in which the youngest dependent reaches the age of 18, payments under this section may be paid on a pro rata basis for the period of time before that dependent reaches the age of 18.
IV. Payment of all benefits.
The Secretary may pay any benefits under this Program through lump-sum payments.
If the Secretary determines that there is a reasonable likelihood that the payments of benefits to a requester will be required for a period in excess of one year from the date the requester is deemed eligible for such benefits, the Secretary may make a lump-sum payment, purchase an annuity or medical insurance policy, or execute an appropriate structured settlement agreement, provided that such payment, annuity, policy, or agreement is actuarially determined to have a value equal to the present value of the projected total amount of benefits that the requester is eligible to receive. Any payment of benefits made over a period of multiple years will be indexed to the Consumer Price Index on an annual basis.
Lump sum payments will be made through an electronic funds transfer to an account of the requester. However, if the requester is a minor or a legally incompetent adult, the legal guardian must establish a guardianship or conservatorship of the estate account with court oversight, in accordance with State law, and payment will be made to that account.
The Secretary may make interim payments of benefits under this Program, even before he makes a final determination as to the total type and total amount of benefits that will be paid. The Secretary will only make an interim payments of benefits after he has calculated that type or subset of benefits. For example, the Secretary may, in certain cases, make an interim payment of medical benefits that have been calculated before a final determination on benefits for lost employment income is completed, or of past medical benefits that have been calculated before a final calculation of future medical benefits is completed. Any payments made on an interim basis will not entitle a requester to seek reconsideration of the Secretary=s decision on these benefits until the Secretary makes a complete benefits determination.
The Secretary=s right to recover benefits paid under this Program from third-party payors.
Upon payment of benefits under this Program, the Secretary will be subrogated to the rights of the requester and may assert a claim against any third-party payor with a legal or contractual obligation to pay for (or provide) such benefits and may recover from such third-party payor(s) the amount of benefits paid up to the amount of benefits the third-party payor has or had an obligation to pay for (or provide). The circumstances in which the Secretary may assert this right include those in which the Secretary pays benefits under this Program to a requester before a final decision is made that a third-party payor has an obligation to pay such benefits to the requester. Requesters receiving benefits under this Program (or their representatives) shall assist the Secretary in recovering such benefits.
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| File Type | application/msword |
| File Title | SMALLPOX EMERGENCY PERSONNEL PROECTION ACT FUND |
| Author | Hrsa |
| Last Modified By | HRSA |
| File Modified | 2007-08-03 |
| File Created | 2007-07-31 |