Administrators - How do I file for CICP benefits if I am the administrator of an estate of a deceased injured countermeasure recipient?

If you are an administrator of the estate of a deceased injured countermeasure recipient, you must submit the following:

1. A completed Request for Benefits Form (PDF - 316 KB) filed within one (1) year of the receipt of the covered countermeasure.
2. A death certificate for the deceased countermeasure recipient. If the death certificate is not available, then the administrator or executor of the estate must submit a letter providing the reasons why it is not available.
3. Documentation showing you are the administrator or executor of the estate of the deceased countermeasure recipient (e.g. Letter of Administration from a court).
4. If not previously submitted, the deceased injured countermeasure recipient’s complete medical records, including primary care visits, specialists, consultations, hospitalizations, as well as the immunization record in the case of vaccine injuries.
5. Any other documentation to show that the deceased person had received a covered countermeasure and sustained a covered injury.

You must submit medical records dating back one year prior to the receipt of the covered countermeasure until the time of death, so that the CICP can assess the deceased injured countermeasure recipient’s total health picture.

You must also complete an Authorization for Use or Disclosure of Health Information Form for each healthcare provider (e.g. doctor, specialist, hospital) the deceased injured countermeasure recipient saw during the time frame indicated above and request that they send the records to the CICP. You must also submit a duplicate copy of each Form to the CICP so that the Program knows which medical records to expect. If the healthcare provider(s) prefers that you request medical records using their own authorization form, the CICP will accept a copy of that form.

For security reasons, the CICP does not accept medical records sent by email.

The CICP will not begin a medical review until all records are received.

If an injured countermeasure recipient submits a complete Request for Benefits Package and then dies before eligibility is determined and you are the administrator of their estate, please contact the CICP at 301-443-9350 for guidance on amending a Request for Benefits.