Form 2 CICP Authorization Form

Form No: CICP-2

OMB Control Number: 0915-0334
Expiration Date: 1/31/2020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration
Countermeasures Injury Compensation Program

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
PLEASE COMPLETE ALL APPLICABLE SECTIONS, SIGN, AND DATE

I. PATIENT IDENTIFICATION (Injured Countermeasure Recipient)
NAME (Last)

FOR OFFICIAL CICP USE ONLY
CICP No. _____________________

(First)

(MI)

ADDRESS
DATE OF BIRTH

CITY/STATE/ZIPCODE
II.

_______________________________________________________________________
Personal Representative, if applicable, for injured countermeasure recipient/ patient in section I
(e.g. parent of a minor or guardian, administrator for estate)

III. The information is to be disclosed by:
Name of Facility/Provider

And is to be provided to:
U.S. Department of Health and Human Services
Health Resources and Services Administration
Countermeasures Injury Compensation Program
5600 Fishers Lane, Room 08N146B
Rockville, MD 20857

Address
City/State/Zip Code

IV. The information to be disclosed from the patient’s, as identified in section I, health record (check appropriate box(es)).
 Entire medical records from __________ to the present (see instructions for appropriate date)
 Only information (e.g. medical records) related to (specify injury or cause of death)_________________________
 Other (specify, e.g., insurance coverage, billing, etc.) ______________________________________________
The purpose or need for this disclosure is to determine eligibility for benefits from the U.S. Department of Health and Human Services,
Health Resources and Services Administration, Countermeasures Injury Compensation Program (CICP). This information may be used
for certain medical research purposes when consistent with the purposes for which the CICP was formed, e.g., gathering and sharing deidentified data regarding countermeasures adverse events.

V. I understand that I may revoke this authorization in writing at any time by contacting my facility/provider, except to the
extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate
one year from the date of my signature unless a different expiration date or expiration event is stated.
______________________________
(Enter Date of Termination or Expiration if different from one year after date below)

VI. SIGNATURE OF PATIENT

DATE

VII. SIGNATURE OF PERSONAL REPRESENTATIVE (if applicable)

DATE

VIII. SIGNATURE OF WITNESS (if signature is thumbprint or mark, or if

DATE

required by State law)

Consenting to this authorization of disclosure of records is voluntary and health provider(s) shall not condition treatment upon the
individual’s signature of such authorization for use or disclosure of health information. This information is subject to release for the
purposes stated in Section IV and may not be used by the recipient for any other purpose unless permitted by federal law. I understand that
information disclosed by this authorization, except for alcohol and drug abuse patient records as defined in 42 CFR Part 2, may be subject
to re-disclosure by the recipient and may no longer be protected by the Health Insurance Portability and Accountability Act Privacy Rule
(45 CFR Part 164), and the Privacy Act of 1974 (5 USC 552a).
Last Updated: October 25, 2011

Form No: CICP-2

OMB Control Number: 0915-0334
Expiration Date: 1/31/2020

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration
Countermeasures Injury Compensation Program

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

PRIVACY ACT STATEMENT
Section 319F-4 of the Public Health Service Act (PHS Act), Public Law 109-148 (42 U.S.C. 247d-6e), and the
Debt Collection Improvement Act of 1996 authorize collection of this information. It will be used to determine
your eligibility to receive benefits. This information will be disclosed to the U.S. Department of Health and
Human Services and its consultants; and Federal, State, or local law enforcement agencies, if the Government
becomes aware of a possible violation of civil or criminal law; and for certain medical research purposes when
consistent with the purposes for which the Program was formed, i.e., to make determinations concerning alleged
covered countermeasure injury associations and to provide compensation to individuals injured by covered
countermeasures. Furnishing the information on this Form, including the social security number, is voluntary,
but failure to do so may delay or prevent the receipt of a payment. The information collected will be
maintained confidentially pursuant to the Privacy Act, 5 USC Section 552a, as amended.
PUBLIC BURDEN STATEMENT
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. The OMB control number for this project is 09150334. Public reporting burden for this collection of information is estimated to average 5 hours per respondent
annually, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville,
Maryland, 20857

Last Updated: October 25, 2011

Form No: CICP-2

OMB Control Number: 0915-0334
Expiration Date: 1/31/2020

Instructions for Completing
HRSA AUTHORIZATION FOR USE OR DISCLOSURE OF
HEALTH INFORMATION
Type or print legibly in all fields using dark ink.
Section I – Provide the name, address, and date of birth of the injured countermeasure recipient.
Section II – Provide the name of the personal representative such as a parent of a minor, or a guardian, or an
attorney, if applicable. If there is no personal representative then section II should be left blank.
Section III – Provide the name and address of the facility or provider releasing the information. This is the
facility or provider of health care services to the injured countermeasure recipient.
Section IV – Check the appropriate box as applicable. The CICP will provide direction as to which records are
needed.
1. Entire Medical Record – the complete medical record from the identified facility or provider from
one (1) year prior to administration or use of the covered countermeasure that may have caused
the injury. Please enter this date.
2. Only information related to – specify diagnosis, injury, operations special therapies, etc. within a
specific date range. (Only complete this section if instructed to do so by the CICP).
3. Other (specify) – e.g., insurance coverage, billing, etc. (Only complete this section if instructed to
do so by the CICP).
Section V – The requester may revoke this authorization at any time by notifying the Health Information
Management (Health Records) Department of the facility/provider in Section III, in writing. If a different

expiration date is desired, specify a new date. You may consider providing a date longer than one year if you
have an ongoing CICP covered injury that has not resolved or may not be resolved soon.
Section VI – Patient (i.e., the injured countermeasure recipient) signs and dates the form here.
Section VII – A personal representative (e.g., parent, legal guardian, power of attorney etc.), if one has been
designated, signs and dates the form here.
Section VIII – A witness signs and dates the form here, if necessary (e.g., if the patient signature is a thumbprint
or mark or if required by State law).
Send a copy of the completed form to the facility/provider identified, and, at the same time, also mail a copy
of the completed form to the CICP at the address below:
Health Resources and Services Administration
Countermeasures Injury Compensation Program
5600 Fishers Lane, Room 11C-06
Rockville, MD 20857
If you have questions contact the CICP at:
1-855-266-2427 (855-266-CICP); or
www.hrsa.gov/countermeasurescomp

Last Updated: October 25, 2011