10112023 - (02) Insufficient Documentation - Blank RFB Form

Health Systems Bureau

5600 Fishers Lane

Rockville, MD 20857

Date

Name

Address

Address

Case Number: CICPNumerical Case Number

Dear Salutation. Last Name:

This letter is to inform you that the Request for Benefits (RFB) form that you filed with the U.S. Department of Health and Human Services’ (HHS) Countermeasures Injury Compensation Program (CICP or the Program) is incomplete. Specifically, you did not provide a response to the question in section A: “Describe the injury that may have resulted from the countermeasure.” The Program will treat the incomplete RFB you filed as a Letter of Intent to file a CICP claim for purposes of the filing deadline (meaning as long as it was filed within one year from date of administration or use of the countermeasure, the claim will be considered timely filed). 42 C.F.R. §110.42(b). However, you are still required to submit “[a] completed and signed Request Form.” 42 C.F.R. §110.51(a)(1). Because the RFB is incomplete, there is currently insufficient documentation for the Program to make a determination concerning your eligibility for CICP benefits. See 42 C.F.R. §110.71. Within 60 calendar days from the date of this letter, you must submit to the CICP a completed RFB form that describes “the injury that may have resulted from the countermeasure.” If insufficient documentation is submitted in response to this letter, the CICP may disapprove the Request for Benefits. 42 C.F.R. § 110.71.

If you are unable to submit a completed RFB form, you may provide a written explanation of the reason(s) why and the efforts you made to submit a completed RFB form. The CICP may accept such a statement in place of the required documentation or disapprove the Request for Benefits due to insufficient documentation.

Please submit the completed RFB form online at injurycompensation.hrsa.gov (preferred). If you are unable to submit these records electronically, please send them to the following address:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 8W-25A

Rockville, MD 20857

Please note that if you disagree with the CICP’s eligibility determination and you request a reconsideration of the determination by an independent panel, the panel cannot review any new documentation that was not previously submitted to the Program. 42 C.F.R. §110.90(a).

If you have questions, please call 1-855-266-2427, email CICP@HRSA.gov, or mail them to the address above.

Sincerely,

CDR George Reed Grimes, MD, MPH

Director, Division of Injury Compensation Programs

Health Resources and Services Administration

www.hrsa.gov