Lists the 9/11-related conditions a private treating physician has diagnosed (onset and diagnosis dates) with supporting records, so the VCF can verify eligibility for claimants using the Private Physician process instead of the WTC Health Program.
- Completed by
- Treating physician or the claimant (one form per physician)
- Issued by
- U.S. Department of Justice, September 11th Victim Compensation Fund (VCF)
- Format
- Fillable PDF
- Language
- English