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VCF Treating Physician Information Form (9/11)

Claimants to the September 11th Victim Compensation Fund whose conditions are not certified by the World Trade Center Health Program may be approved for the Private Physician process. For each treating physician, this form lists the conditions treated with the earliest symptom onset and first diagnosis dates, plus the physician's licensing and specialty details, so the VCF can verify the conditions for compensation.

Who completes it

Either the treating physician or the claimant may complete it, one form per treating physician. Page 2 needs the physician's contact details, state license numbers, and specialties with AMA physician specialty codes.

Submitting and payment

How to submit it
Upload it to the online VCF claim under the Private Physician Forms document type, or mail it with the full packet and the return cover sheet. The VCF asks that all completed forms be gathered and sent together.

Good to know

  • Do not submit the forms until the VCF has notified the claimant that they are approved for the Private Physician process.
  • Attach records supporting each diagnosis; the WTC Health Program's Diagnostic Essentials for Physical Health Conditions lists the information needed to verify a condition.
  • If treatment caused complications that led to new diagnoses, summarize them on the form and include the medical records.
  • The packet also includes Appendix C (New York City site) or Appendix D (Pentagon and Shanksville), exposure questionnaires for the claimant. No edition date is printed on the form.

Get the official form

Download the current version from the source each time; forms change without notice.

Treating Physician Information Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Who is eligible for the VCF Private Physician process?

Claimants the VCF directs to it, those filing for a deceased person not certified by the WTC Health Program for the claimed condition, and those living outside the continental U.S. Claimants who cannot reach a WTC Health Program center without significant hardship must first get VCF approval.

Does the physician have to fill out the VCF Treating Physician Information Form?

No. The form states it may be completed by the physician or the claimant. Each treating physician needs a separate form, and copies of relevant records supporting the listed diagnoses should be included.

What records support a 9/11 condition with the VCF?

The VCF points to the WTC Health Program's Diagnostic Essentials for Physical Health Conditions, revised November 26, 2021, which specifies the documentation required. Related guidance covers time intervals for new-onset aerodigestive disorders and minimum latency for types of cancer.