07. Medical Last Chance Letter

Health Systems Bureau

5600 Fishers Lane

Rockville, MD 20857

Date.

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Case Number: CICPClick or tap here to enter text.

Dear Click or tap here to enter text. Click or tap here to enter text.:

This letter is to determine if the U.S. Department of Health and Human Services’ (HHS) Countermeasures Injury Compensation Program (CICP or the Program) has received all documentation you intend to submit for consideration of the Request for Benefits Package (Request Package) that you filed.

Documentation Received

The CICP has received the following documents pertaining to your claim for CICP benefits:

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Next Steps

If you plan to submit additional documents, you must submit the additional documents within 60 calendar days from the date of this letter. A form response (optional) has been included for your convenience. The response and any additional records can be returned via the CICP’s electronic portal at injurycompensation.hrsa.gov (preferred). If unable to submit electronically, please send this form to the CICP at the address below:

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 8W-25A

Rockville, MD 20857

While not required, you may submit additional medical documentation that you believe will support your Request Package. This may include additional medical documentation or scientific evidence in order to establish that an injury was caused by a covered countermeasure.¹ Letters from treating physicians may be submitted as additional evidence but may not substitute for the required medical documentation. 42 C.F.R. §110.50(b).

If the CICP does not receive additional documents from you within 60 calendar days from the date of this letter, does not receive a response from you, or receives a response that you do not plan to submit any additional documentation, the CICP will proceed with its review of your claim and make an eligibility determination based on the documentation it has at that time.

Please note that if the CICP makes an eligibility determination with which you disagree 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 the CICP at CICP@HRSA.gov, or send them to the address above.

Sincerely,

CDR George Reed Grimes, MD, MPH

Director, Division of Injury Compensation Programs

Response Form (Optional)

Please return by submitting via the CICP’s electronic portal at https://injurycompensation.hrsa.gov/ (preferred). If unable to submit 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 check the box of the statement that applies to you. Select only one option below.

I do not plan to submit any additional documentation. Please review my file for eligibility based on what has already been submitted, and do not wait the 60 days outlined in CICP’s letter.

I plan to submit the following additional documentation within 60 calendar days from the date of CICP’s letter.

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Name of Requester (Please print) CICP Case Number

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Signature

1 To establish causation, a requester must demonstrate that the covered injury occurred as a direct result of the administration or use of a covered countermeasure based on compelling, reliable, valid, medical and scientific evidence. 42 C.F.R. §110.20(c).

Health Resources and Services Administration

www.hrsa.gov