If you are a survivor of a deceased countermeasure recipient, you must submit the following:
- A completed Request for Benefits Form filed within one (1) year of the receipt of the covered countermeasure.
- A death certificate for the deceased injured countermeasure recipient. If the death certificate is not available, then a survivor must submit a letter providing the reasons why it is not available.
- Documentation showing you are an eligible survivor, such as a birth or marriage certificate.
- 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.
- 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.
Learn more about the CICP Filing Process.