Private Physician Process: Forms and Resources

These Private Physician forms should only be used if you meet one of the following criteria:

• You received specific direction from the VCF to complete the forms; or
• You are filing a claim for a deceased individual who was not certified for treatment by the WTC Health Program for the claimed condition; or
• You are a foreign resident, living outside the continental United States, who has not been certified for treatment by the WTC Health Program for the claimed condition; or
• You do not qualify for certification by the WTC Health Program because you do not meet the program enrollment requirements; or
• You are not able to go to a WTC Health Program center (either in the New York City metropolitan area or through the Nationwide Provider Network) to have your condition evaluated and certified for treatment without suffering significant hardship. If you believe that you will suffer significant hardship in seeking certification by the WTC Health Program, you should upload a statement or letter to the claim explaining the circumstances and why you should be considered for the Private Physician process and call the VCF Helpline to alert us to the request.

If you do not meet the criteria above, you should not complete the Private Physician forms.

You can review Frequently Asked Questions ("FAQs") specific to the Private Physician process in Section 7 of our FAQs.

Individual Forms:

• Private Physician Process Instructions
• Private Physician Packet: NYC Site  (Claim Form Appendix C)
• Private Physician Packet: Pentagon and Shanksville, PA Sites  (Claim Form Appendix D)
• Treating Physician Information Form
• Authorization for Release of Medical Records: Personal Injury Claimants
• Authorization for Release of Medical Records: Claims for Deceased Individuals
• Cover Sheet for Returning Forms

WTC HEALTH PROGRAM GUIDANCE

The WTC Health Program has published the following materials related to the VCF Private Physician process. Claimants are strongly encouraged to review these materials before completing the Private Physician forms.

• Diagnostic Essentials for Physical Health Conditions: (Revised: November 26, 2021) These guidelines outline the specific documentation that is required in order to verify a condition for compensation from the VCF.
• WTC Health Program Time Intervals for New Onset Aerodigestive Disorders (Updated: August 30, 2017)
• Minimum Latency and Types or Categories of Cancer (Revised: April 16, 2021)

Visit the WTC Health Program website for more information.

IMPORTANT REMINDERS

• If you enter information into one of these files and save it to your computer, please save the file with a new name. Please also remember that the file contains personal information. You may not want to save the file on a public or shared computer where others have access.
• We can process your claim faster if you gather all the completed forms and relevant documents and upload them to your online claim at the same time or return them in one mailing. When uploading any portion of the Private Physician forms to the online claim, please select from the Eligibility document types and choose "Private Physician Forms" as the applicable document type.