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How to File and Deadline for Filing

Individuals have one (1) year from the date the vaccine or other covered countermeasure was administered to request compensation benefits.

The Request for Benefits package, which is the official application to the CICP, must be completed by every requester of benefits.

Individuals who would like to file a CICP Request for Benefits may download the files from this page, which are available as PDF or Word documents.  Alternatively, you may request that a hard copy of the package be sent to you, by calling 1-855-266-CICP (2427).

The Request package consists of the following documents:

  1. Instructions for Completing the Request for Benefits Forms
  2. Request for Benefits Form (PDF)
  3. Instructions for Completing the Authorization for Use or Disclosure of Health Information Form
  4. Authorization for Use or Disclosure of Health Information Form (PDF)

Please review all of the instructions thoroughly before you complete the forms.  Pages 5 - 7 of the Instructions will guide you in determining which category of requester best describes you.  All of the applicable forms must be filled out completely.  You may use as many Authorization Forms as you need.  Please be aware that the CICP must receive all medical records from each health care provider as described in the instructions, before the review for eligibility can begin.

If you download the forms from this website, please print them and submit the hard copies either by U.S. mail or by fax.  At this time, the CICP cannot accept electronic submissions.

Please mail your Request for Benefits to:

Health Resources and Services Administration 
Countermeasures Injury Compensation Program 
5600 Fishers Lane, Room 11C-06 
Rockville, MD 20857

Although it is not required, requestors may engage the services of an attorney or other representative to render services in connection with the request for benefits. However, the payment of fees and/or costs by CICP of an attorney or other representative is not permitted.

Date Last Reviewed:  April 2017

Countermeasures Injury Compensation Program


Program Rules & Regulations

PREP Act Declarations

Covered Countermeasures

Types of Benefits

How to File and Deadline for Filing

Programa de compensación por daños causados por contramedidas

Frequently Asked Questions

Contact Us: or 1-855-266-CICP (2427).  

For your security, please do not send any personal information (Social Security Number, medical, legal, or financial documents, etc.) by email to the Program.  

Please call the above number and you will receive information on sending emails safely and securely.  

Covered Countermeasures

Seasonal influenza vaccines are not covered countermeasures under the CICP. If you received the seasonal influenza vaccine or other vaccines covered by the National Vaccine Injury Compensation Program (VICP) such as tetanus or the human papillomavirus vaccine and think that you had an adverse reaction from one or a combination of these covered vaccines, see the VICP.


CICP Request for Benefits Form Instructions 
(Word) (PDF - 60 KB)
CICP Request for Benefits Forms 
(Word) (PDF - 78 KB)
Health Information Disclosure Form (Word) (PDF - 36 KB)