Benefits Package and Supporting Documentation

ATTACHMENT 1 OMB Number: 0915-0334

Expiration date: (9/30/2016)

C

ountermeasures Injury Compensation Program (CICP)

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

Lost Employment Income --Estates

To calculate the benefits to be reimbursed or paid for medical services and/or lost employment income, the CICP requires that you, as the representative of the estate, submit specific documentation. The documentation that you submit will depend on the benefits requested and third-party coverage the deceased injured countermeasure recipient may have had.

For each of the two sections below, please choose one of the descriptions that best fits the deceased injured countermeasure recipient’s situation.

Section I. Unreimbursed Medical Expenses

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

1. If you are NOT requesting any payment or reimbursement for the deceased injured countermeasure recipient’s 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 the deceased injured countermeasure recipient’s unreimbursed medical expenses related to the countermeasure injury and there are NO 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 the latest itemized statement(s), bill(s), and/or receipt(s) from each healthcare provider (e.g., clinic, hospital, doctor’s office, or pharmacy) where the deceased injured countermeasure recipient 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.

3. If you ARE requesting payment or reimbursement for the deceased injured countermeasure recipient’s unreimbursed medical expenses and there ARE third-party payers for all or part of the 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 the deceased injured countermeasure recipient’s health insurance company) expected or obligated to pay for the medical services or items used to diagnose or treat the deceased injured countermeasure recipient’s covered injury or health complications of that injury. Indicate the amounts that have been paid and amount still required to be paid 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.

1. If you are NOT requesting lost employment income benefits on behalf of the deceased injured countermeasure recipient, 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 the deceased injured countermeasure recipient’s lost employment income related to the countermeasure injury and there are NO third-party payers for 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 the deceased injured countermeasure recipient lost employment income (e.g., a time sheet from the pay period(s) showing work days missed) and documentation of unpaid leave status.

• Gather the deceased injured countermeasure recipient’s Federal tax return or pay stub(s) from all employers showing their gross employment income at the time the covered injury was sustained.

• Gather the deceased injured countermeasure recipient’s Federal tax return for the year in which the covered injury was sustained, if they had dependents.

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

3. If you ARE requesting payment or reimbursement for the deceased injured countermeasure recipient’s lost employment income related to the countermeasure injury and there ARE third-party payers 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 providing lost employment income benefits for the deceased injured countermeasure recipient 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 the deceased injured countermeasure recipient lost income (e.g., a time sheet from the pay period(s) showing work days missed) and documentation of unpaid leave status.

• Gather the deceased injured countermeasure recipient’s Federal tax return or pay stub(s) from all employers showing their gross employment income at the time the covered injury was sustained.

• Gather the injured countermeasure recipient’s Federal tax return for the year in which the covered injury was sustained, if he/she had dependents.

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

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

Please fill out the Certifications of Status (Attachments 2 and 3) and send the Certifications and all the documents that apply to the injured countermeasure recipient, to the address below. 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 08N146B

Rockville, MD 20857