Injury Compensation Programs

Select one filing method only. Do not submit the same requests electronically and by mail.

To electronically submit a CICP Request for Benefits, login above and select the Start New Request button under Submit a Request Package to CICP on the home page.

The following Authorization for Use or Disclosure of Health Information form can be completed and uploaded at the time of your submission electronically:

• Instructions for the Authorization for Use or Disclosure of Health Information form* (PDF - 42 KB)
• Authorization for Use or Disclosure of Health Information form* (PDF - 162 KB)
• Please note that you need to fill out a separate form for each healthcare provider who treated you.

For more information about CICP: 1-855-266-2427 (CICP) or cicp@hrsa.gov.

Select one filing method only. Do not submit the same requests electronically and by mail.

Please read thoroughly before filling out your Request for Benefits forms:

• Instructions for the Request for Benefits Form* (PDF - 42 KB)
• Instructions for the Authorization for Use or Disclosure of Health Information form* (PDF - 42 KB)

Please complete thoroughly:

• Request for Benefits form* (PDF - 246 KB)
• Authorization for Use or Disclosure of Health Information form* (PDF - 162 KB)
• Please note that you need to fill out a separate form for each healthcare provider who treated you.

Please make sure:

• Your Request for Benefits forms are sent to the CICP via U.S. Postal Service mail or a private courier. CICP does not accept Request for Benefits forms via fax or email.
• CICP receives all medical records from each health care provider who treated you. These are generally all of the medical records from one year before the administration or use of the covered countermeasure to the present time. The records also need to be sent to the CICP by U.S. Postal Service mail or private courier service.

The CICP is not authorized to provide reimbursement for attorneys’ fees. You may elect to use an attorney; however, you are responsible for any attorney’s fees or costs incurred.

You can file Request for Benefits form without other documents.

For more information about CICP: 1-855-266-2427 (CICP) or cicp@hrsa.gov.

Select one filing method only. Do not submit the same requests electronically and by mail. CICP does not accept Letters of Intent via fax or email.

A Letter of Intent to file a Request for Benefits Form may be submitted to ensure that you meet the one-year filing deadline. However, if you submit a Letter of Intent, you must still file Request for Benefits Forms as soon as possible.

To electronically submit a CICP Letter of Intent, login above. Select the option “Upload Additional Documents”, and then upload your letter of intent.

To file a CICP Letter of Intent via mail, send documentation through U.S. Postal Service mail or a private courier to the following address:

U.S. Department of Health and Human Services

Health Resources and Services Administration

Countermeasures Injury Compensation Program

5600 Fishers Lane, 08N146B

Rockville, MD 20857

The postmark or its equivalent (e.g., the delivery date provided by the commercial carrier) will be considered the filing date to determine if you met the filing deadline.

Please make sure:

• A Letter of Intent includes your full name and a statement that indicates your intent to submit a Request for Benefits. Please do not include any additional personal identifiable information (Social Security Number, medical, legal, or financial documents) in this letter.

For more information about CICP: 1-855-266-2427 (CICP) or cicp@hrsa.gov.

• Request for Benefits form (electronic filing or mail fillable PDF)
• Proof of administration or use of a covered countermeasure, such as proof of vaccination (e.g., CDC COVID-19 Vaccination Record card) in the case of vaccine injury claims
• Authorization for Use or Disclosure of Health Information form (PDF - 161 KB). Please note that you need to fill out a separate form for each health care provider who treated you and send the original form to your health care provider. Also, please send copies of each authorization form to the CICP.
•  The following medical records submitted by you or your health care provider(s) (CICP prefers that medical records are sent directly to the program by your healthcare providers)
  • All medical records documenting medical visits, procedures, consultations, and test results that occurred on or after the date of administration or use of the covered countermeasure.
  • All hospital records, including the admission history and physical examination, the discharge summary, all physician subspecialty consultation reports, all physician and nursing progress notes, and all test results that occurred on or after the date of administration or use of the covered countermeasure.  
  • All medical records for one year prior to administration or use of the covered countermeasure as necessary to indicate an injured countermeasure recipient’s pre-existing medical history.
  • Death certificate if filing on behalf of a deceased countermeasure recipient    
  • Download this checklist as a PDF