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Request Form Instructions
A complete
Request Package consists of a completed and signed
Request Form and the required documentation. However,
a request for benefits will be considered timely filed
as long as a completed and signed Request Form is
postmarked within the period described in the regulations,
included in these instructions in the paragraph entitled
Filing Deadlines.
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Acrobat/pdf Request Package
(includes Request Form & Instructions, Certification
Form & Instructions)
For the purposes of the
Smallpox Vaccine Injury Compensation (SVIC) Program,
a Smallpox Vaccine Recipient
is defined as: |
- a
health care worker, law enforcement officer,
firefighter, security personnel, emergency
medical personnel, other public safety personnel,
or support personnel for such occupational
specialties who has volunteered and been selected
to be a member of a smallpox emergency response
plan prior to the time at which the Secretary
publicly announces that an active case of
smallpox has been identified within or outside
of the United States;
- who
is or will be functioning in a role identified
in an HHS-approved smallpox emergency response
plan (a Plan);
- to
whom a smallpox vaccine is administered pursuant
to a Plan during the effective period of the
Declaration.*
|
A Vaccinia Contact is defined
as: |
- someone
who contracted vaccinia during the effective
period of the Declaration* (or within 30 days
after the end of such period);
- prior
to contracting vaccinia, was accidentally
inoculated by a smallpox vaccine recipient
or a contact of such a person.
|
A Covered Injury is defined
as an injury that the Secretary determines: |
- meets
the requirements of the Table (which is presumed
to be the direct result of the administration
of a smallpox vaccine or accidental vaccinia
inoculation); or
-
was more likely than not, the direct result
of:
(A) the administration of a covered countermeasure
(including the smallpox vaccine) during the
effective period of the Declaration*, in the
case of a smallpox vaccine recipient; or
(B) vaccinia contracted through accidental
vaccinia inoculation (and not the result of
receiving a smallpox vaccine) during the effective
period of the Declaration* (or within 30 days
after the end of such period), in the case
of a vaccinia contact.
|
An injured smallpox vaccine
recipient is defined as: |
- a
smallpox vaccine recipient who sustained a
covered injury.
|
An injured vaccinia contact
is defined as: |
- a
vaccinia contact who sustained a covered injury.
|
For a
list of required documentation
for eligibility determinations, see Attachment 1.
For a list of the benefits documentation
under the SVIC Program, see Attachment 2.
Filing Deadlines
A Request
Form concerning an injured smallpox vaccine recipient
must be postmarked within 1 year of his or her receiving
a smallpox vaccination under a Plan.
A Request Form concerning an injured vaccinia contact
must be postmarked within 2 years of the date of the
onset of his or her medical injury.
General Instructions for all
Requesters
A.
Complete the relevant sections of the Request Form.
All requesters must complete Section A of the Request
Form, which requires information regarding the individual
who was medically injured, either as a smallpox vaccine
recipient or as a vaccinia contact, and Section E,
the Request Form signature section. All information
that you submit will be maintained and protected in
accordance with the Privacy Act.
B.
Consult the Documentation Checklist for the category
of eligibility that best describes you. Then
provide the required documentation listed with your
category to support your Request Form. A requester
is not required to submit any documentation pertaining
to benefits until the Secretary has informed the requester
that he or she is eligible under the Program.
C. Submit
your Request Form and all the required documentation to the SVIC Program by U.S. mail, by
a private courier service or commercial carrier to:
Smallpox Vaccine Injury Compensation Program Office
5600 Fishers Lane, Room 11C-26
Rockville, MD 20857
D.
A separate Request Form must be submitted for each
medically injured person who may be eligible for benefits
payment
(i.e., a smallpox vaccine recipient or a vaccinia
contact).
E.
Multiple survivors may submit one Request Form for
the death benefit (e.g., the surviving children
and spouse, or surviving children if there is no surviving
spouse). Survivors may also submit separate Request
Forms.
F.
Keep a copy of all forms and documentation
that you submitted for your own records.
Changes
in Information Provided
Should
there be a change in the information you provided
with your Request Form or in your documentation, you
are required to notify in writing the SVIC Program
Office at either of the addresses above. Please note
that if you fail to provide the Program with this
information, the Program may not be able to contact
you regarding the processing of your Request Package.
Request
Form Instructions
Section A Instructions
- This
section is required for all requesters
This section
describes an injured smallpox vaccine recipient or
vaccinia contact. If a Request Form is filed on behalf
of an injured smallpox vaccine recipient, complete
A1. If a Request Form is filed on behalf of an injured
vaccinia contact, complete A2.
Section
A1 describes an injured smallpox vaccine recipient.
Name: The full name of the smallpox vaccine
recipient.
Social Security Number: That individual’s
9-digit Social Security Number.
Date of Birth: That individual’s
date of birth (month, day, and year).
Type of injury from the vaccination or other
covered countermeasure: A brief description
of the medical injury (e.g., scarring, Stevens-Johnson
Syndrome, etc.).
The number of days of lost employment income
resulting from the medical injury: Enter
the number of days away from work caused by the medical
injury and its health complications for which he or
she lost employment income. If the individual lost
partial days (e.g., half of a work day), compute the
number of partial days that total a complete workday,
and enter the number.
Check
here [ ] if the smallpox vaccine recipient had a dependent
under the age of 18 at the date of the onset of medical
injury. Whether an individual had at least
one dependent (as defined by the Internal Revenue
Service) under the age of 18 at the time of the covered
injury affects the available amount of benefit for
lost employment income.
If the smallpox vaccine recipient is no longer
living, provide the date of death: The smallpox
vaccine recipient’s date of death, if applicable (month,
day, and year).
If the smallpox vaccine recipient is still
living:
Address: That individual’s current
home address.
City: That individual’s current city
of residence.
State: That individual’s current
state of residence.
Zip Code: The 5 or 9 digit zip code
for that individual’s current residence.
Daytime telephone number(s): That
individual’s telephone number(s), including the area
code, where he or she can be reached during business
hours.
Section
A2 describes an injured vaccinia contact.
Name: The full name of the injured vaccinia
contact.
Social Security Number: That individual’s
9-digit Social Security Number.
Date of Birth: That individual’s
date of birth (month, day, and year).
Type of injury from the vaccinia:
A brief description of the medical injury (e.g., scarring,
encephalopathy, etc.).
The number of days of lost employment income
resulting from the medical injury: Enter
the number of days away from work caused by the medical
injury and its health complications for which he or
she lost employment income. If the individual lost
partial days (e.g., half of a work day), compute the
number of partial days that total a complete workday,
and enter the number.
Check
here [ ] if the smallpox vaccine recipient had a dependent
under the age of 18 at the date of the onset of injury.
Whether an individual had at least one dependent (as
defined by the Internal Revenue Service) under the
age of 18 at the time of the covered injury affects
the available amount of benefit for lost employment
income.
If the vaccinia contact is no longer living,
provide the date of death: The vaccinia contact’s
date of death, if applicable (month, day, and year).
If the vaccinia contact is living:
Address: That individual’s current
home address.
City: That individual’s current city
of residence.
State: That individual’s current
state of residence.
Zip Code: The 5 or 9 digit zip code
of that individual’s current residence.
Daytime telephone number(s): That
individual’s telephone number(s), including the area
code, where he or she can be reached during business
hours.
Source
of Exposure to Vaccinia. The requester must
indicate if the injured vaccinia contact contracted
vaccinia from a smallpox vaccine recipient or a vaccinia
contact. If the vaccinia contact’s source of exposure
is unknown, the requester must explain the circumstances
by which the contact contracted vaccinia.
- Check
the first box if the source of vaccinia was a smallpox
vaccine recipient. Enter the smallpox vaccinia recipient’s
name in the line provided.
- Check
the second box if the source of vaccinia was person
who contracted vaccinia from a smallpox vaccine
recipient. Enter the names of the vaccinia contact
and the smallpox vaccine recipient in the places
provided.
- Check
the third box if the source of vaccinia is unknown,
and explain the source of the vaccinia exposure.
Attach a separate sheet describing the circumstances
surrounding the accidental vaccinia exposure that
led to the contracting of vaccinia. Be as specific
as possible.
Section
B Instructions
- Complete
this section if you are filing a Request Form as
a survivor of a smallpox vaccine recipient or a
vaccinia contact.
This section
describes the survivors of a deceased smallpox vaccine
recipient or vaccinia contact who died as a direct
result of a covered injury. The following is the list
of individuals who may be eligible for benefits:
- A surviving
spouse.
- Child(ren)
- the definition of “surviving eligible child”
includes: an individual who is a natural, illegitimate,
adopted, or posthumous child, or stepchild, of the
deceased person, and is 18 years of age or younger,
or between 19 and 23 years of age and a full-time
student, or is over 18 years of age and incapable
of self-support because of physical or mental disability.
- Dependent(s)
(as defined by the IRS) younger than 18 years of
age.
- Beneficiary
in the most recently executed life insurance policy
and there are no survivors described above.
- Parent(s)
and there are no survivors described above.
- Legal
guardian of a deceased minor, and there are no survivors
described above.
(Note: If there are minor children under the age
of 18 who were dependents of the deceased, the legal
guardian has the option to select the method of
payment of death benefits. See Section D Instructions
for details).
Name:
The survivor’s full name.
Social Security Number: The survivor’s
9-digit Social Security Number.
Date of Birth: The survivor’s date
of birth (month, day, and year).
Address: The survivor’s current home
address.
City: The survivor’s current city
of residence.
State: The survivor’s current state
of residence.
Zip Code: 5 or 9 digit zip code of
the survivor’s current residence.
Daytime telephone number(s): The
survivor’s telephone number(s), including the area
code, where he or she can be reached during business
hours.
Check
the box that describes the Survivor’s Relationship
to the individual in Section A. Check the
box that best describes the survivor’s relationship
to the deceased individual.
Check the box that indicates if the survivor
is a sole survivor or if there are other survivors
who may be eligible for benefits payment.
If you are the only eligible survivor, check the first
box. If there are other survivors, then list all the
other survivors in the categories listed above on
the Request Form and identify their relationship to
the deceased. If you need more space, append the Request
Form with another page and list all of them.
Check the box if this is a Request Form filed
by multiple survivors and attach another
page listing all the survivors’ names, Social Security
Numbers, dates of birth, complete addresses, and daytime
telephone numbers.
Section
C Instructions
- Complete
this section if you are the representative of the
estate of a deceased smallpox vaccine recipient
or vaccinia contact.
Name:
The estate representative’s full name.
Address: The estate representative’s
current home or office address.
City: The city associated with that
address.
State: The state associated with
that address.
Zip Code: 5 or 9 digit zip code associated
with that address.
Daytime telephone number(s): The
estate representative’s telephone number(s), including
the area code, where he or she can be reached during
business hours.
Section
D Instructions
- Complete
this section if you are a personal representative
acting on behalf of a requester.
This section
describes an attorney or other representative, if
any, for the requester. If this section is completed,
all communications related to the Request Package
will only occur with the personal representative.
Name:
The personal representative’s full name.
Address: The personal representative’s
current home or office address.
City: The city associated with that
address.
State: The state associated with
that address.
Zip Code: 5 or 9 digit zip code associated
with that address.
Daytime telephone number(s): The
personal representative’s telephone number(s), including
the area code, where he or she can be reached during
business hours.
Does
the person you are representing have the legal capacity
to receive benefits? If the requester is
of the age of majority and has the legal capacity
to receive a benefit, check the first box. If the
requester is a minor or has been declared legally
incompetent by a court, then check the second box
and explain why this option was chosen (e.g., the
person is a minor).
The
SVIC Program pays death benefits under two different
calculations: the Standard Calculation and
the Alternative Calculation.
- The
Standard Calculation is based on the U.S. Department
of Justice’s Public Safety Officers’ Benefit (PSOB)
Program. This is the only method of payment for
a surviving spouse, beneficiary in the most recently
executed life insurance policy, parent, and surviving
legal guardian of a deceased eligible individual
under the age of 18. This is also the only method
of payment for a surviving eligible child who is
not the dependent of the deceased person.
- The
Alternative Calculation uses a formula based on
the income of the deceased smallpox vaccine recipient
or vaccinia contact and the age of that person’s
youngest dependent under the age of 18. This is
the only method of payment for a dependent under
the age of 18 of a deceased smallpox vaccine recipient
or vaccinia contact who is not that person’s child
(e.g., a niece or nephew dependent).
The legal
guardian of a dependent under the age of 18 who is
a surviving child has the option to select either
the Standard Calculation or the Alternative Calculation.
Use the space on the Request Form to check the box
for Death Benefit under the Standard Calculation or
Death Benefit under the Alternative Calculation.
For a complete
description of the death benefits, see Attachment
2 at the end of the Request Form Instructions.
Section
E Instructions
Only requesters
or their legal guardians complete this section.
All requesters must sign the Request Form, unless the
requester does not have the legal capacity to receive
payments under the Act. In that case, a legal guardian
must sign for the individual. If multiple survivors
are filing jointly, at least one of these survivors
must sign the Request Form.
Name (type or print clearly): The
name of the person signing the Request Form, presented
legibly.
Signature: An original signature in ink.
Date: Date Request Form was signed (month, day, and
year).
By signing section E, the requester
(or the requester’s legal guardian) is attesting
under penalty of prosecution that all statements in
the Request Form are true and accurate to the best
of his or her knowledge. If the requester has used
a legal or personal representative to submit the Request
Form and documentation, the requester’s signature
also authorizes the personal representative identified
in Section D to interact with the SVIC Program on
his or her behalf.
Request
Package Documentation Checklist
The Documentation Checklist is a listing of the eligibility
and benefits documentation, by category of requester,
which is to be submitted to the Smallpox Vaccine Injury
Compensation (SVIC) Program. Copies of documentation
may be provided in lieu of originals.
In order to meet the filing deadlines as described
in the Request Form Instructions, a requester need
only submit a completed and signed Request Form. However,
in order for the Secretary to determine if the requester
is eligible for benefits under the Smallpox Emergency
Personnel Protection Act of 2003 (the Act), the Secretary
must receive the eligibility documentation.
After the Secretary has determined that a requester
is eligible for benefits under the Act, then the benefits
documentation must be submitted in order for the Secretary
to determine the type and amount of benefits.
In
this checklist on this page: |
|
A. Individuals Who Sustained a Covered Injury
Category of Eligibility and Required Documentation
A1. SMALLPOX VACCINE RECIPIENT
A smallpox
vaccine recipient may be eligible for medical benefits,
lost employment income benefits, or both. Full
definition of a smallpox vaccine recipient
[
] The individual who
- Is or
was a member of an HHS-approved smallpox emergency
response plan
- Received
a smallpox vaccination under the plan during the
period in the Secretary's Declaration, and
- Sustained
a covered injury.
I.
Eligibility documentation
- Smallpox
Vaccine Injury Compensation Program Certification
Form (or other documentation that the individual
received a smallpox vaccination under a Plan); and
- Medical
documentation showing that the smallpox vaccine
recipient:
(a) Received a smallpox vaccination; and
(b) Suffered a medical injury resulting from the
smallpox vaccine or another covered countermeasure
(e.g., cidofovir or vaccinia immune globulin). Include
all related medical records.
II.
Benefits documentation
- Medical
benefits:
(a) Past and current medical expenses.
(b) Potential future medical expenses.
(c) A list of all third-party payors (e.g. insurance
company) that have paid or possibly will pay for
medical services and items to the smallpox vaccine
recipient.
- Lost
employment income benefits:
(a) Documentation of number of days (including partial
days) of lost employment income.
(b) Gross earned employment income at the time of
the covered injury.
(c) A list of all third-party payors (e.g., Worker’s
Compensation) that have or will provide benefits
for loss of employment income or disability or retirement
benefits.
(d) Any documentation of compensation by any of
those third-party payors.
(e) If applicable, documentation that the individual
has as least one dependent under the age of 18 years
(e.g. IRS Form 1040).
Category
of Eligibility Required Documentation
A2. VACCINIA CONTACT
A vaccinia contact may be eligible for medical benefits,
lost employment income benefits, or both. Full
definition of a vaccinia contact
[
] The individual who was exposed to vaccinia by
either a smallpox vaccine recipient or another vaccinia
contact who contracted vaccinia from a smallpox
vaccine recipient.
[ ] sustained a covered injury
I.
Eligibility documentation
- Smallpox
Vaccine Injury Compensation Program Certification
Form that identifies the smallpox vaccine recipient
who was the source of the vaccinia exposure (or
other documentation that the individual received
a smallpox vaccination under a Plan) or other documentation
of the source of exposure to vaccinia.
- Medical
documentation showing that the vaccinia contact
suffered a medical injury resulting from the vaccinia,
and the date that the vaccinia contact contracted
vaccinia. Include all related medical records.
II.
Benefits documentation
- Medical
benefits:
(a) Past and current medical expenses.
(b) Potential future medical expenses.
(c) A list of all third-party payors (e.g. insurance
company) that have paid or possibly will pay for
medical services and items to the vaccinia contact.
- Lost
employment income benefits:
(a) Documentation of number of days (including partial
days) of lost employment income.
(b) Gross earned employment income at the time of
the covered injury.
(c) A list of all third-party payors (e.g., Worker’s
Compensation) who have provided or will provide
benefits for loss of employment income or disability
retirement benefits.
(d) Any documentation of compensation by any of
the those third-party payors.
(e) If applicable, documentation that the individual
has at least one dependent under the age of 18 years
(e.g., IRS Form 1040).
Category
of Eligibility Required Documentation
B. Survivors of a Smallpox Vaccine
Recipient or a Vaccinia Contact
Survivors are eligible for death benefits only.
[
] Surviving spouse of an individual who died as
a direct result of a covered injury.
I.
Eligibility documentation
- All
eligibility documentation required for the smallpox
vaccine recipient (see A1) or
who was a vaccinia contact (see
A2).
- Medical
documentation that the individual you survived died
as a direct result of a covered injury.
- Legal
documentation:
(a) A death certificate for the individual you survived
who died as a direct result of a covered injury.
If a death certificate is not available, other documentation
of that individual’s death; and
(b) A marriage certificate or other proof of lawful
marriage, which shows that you were the spouse of
the individual at the time of that individual’s
death.
II.
Benefits documentation
(a) Public
Safety Officers’ Benefits (PSOB) Program death benefit,
if applicable.
(b) PSOB Program disability benefit, if applicable.
Category
of Eligibility Required Documentation
Surviving Child or Children
[
] Surviving child or children of an individual who
died as a direct result of a covered injury. For
the purpose of the SVIC Program, an eligible child
is:
- A natural,
illegitimate, adopted, or stepchild, of the deceased
individual, and
- 18 years
of age or younger, or
- between
19 and 23 years of age and a full-time student,
or
- over
18 years of age and incapable of self-support because
of physical or mental disability.
(Note:
an eligible child’s Request Form must be submitted
by a personal representative. See Section
D of the Documentation Checklist).
I.
Eligibility documentation
- All
eligibility documentation required for the smallpox
vaccine recipient (see A1 above in the Documentation
Checklist) or who was a vaccinia contact (see A2
above in the Documentation Checklist).
- Medical
documentation that the individual died as a direct
result of a covered injury.
- Legal
documentation
(a) A death certificate for the individual the child
survived who died as a direct result of a covered
injury. If a death certificate is not available,
other documentation of that individual’s death;
and
(b) A birth certificate of the child for age verification.
If the birth certificate does not identify the deceased
as the child’s parent, other documentation that
shows that the child had a child/parent relation
with the individual he or she survived.
II
. Benefits documentation
(a)
Selection of method of payment, either Standard
Calculation of Alternative Calculation (this is
on the Request Form).
(b) if Standard Calculation is selected,
(i)
Public Safety Officers’ Benefits (PSOB) Program
death benefit, if applicable.
(ii) PSOB Program disability benefit, if applicable.
(c) if Alternative Calculation is selected, see
Attachment 2 for the list.
Category
of Eligibility Required Documentation
Surviving Dependent
[ ] Surviving dependent (e.g. niece, nephew, or
grandchild, etc.) under the age of 18 of an individual
who died as a direct result of a covered injury.
(Note:
Request Form on behalf of a surviving dependent under
the age of 18 must be submitted by a personal representative.
See Section D of the Documentation Checklist).
I.
Eligibility documentation
- All
eligibility documentation required for the smallpox
vaccine recipient (see A1 above in the Documentation
Checklist) or who was a vaccinia contact (see A2
above in the Documentation Checklist).
- Medical
documentation that the individual the dependent
survived died as a direct result of a covered injury.
- Legal
documentation
(a) A death certificate for the individual the dependent
survived who died as a direct result of a covered
injury. If a death certificate is not available,
other documentation of that individual’s death;
and
(b) Documentation that shows that the requester
was the dependent of the individual at the time
of that individual’s death.
(c) The dependent’s birth certificate.
III.
Benefits documentation
(a) Selection
of method of payment, either Standard Calculation
of Alternative Calculation (this is on the Request
Form).
(b) if Standard Calculation is selected,
(i)
Public Safety Officers’ Benefits (PSOB) Program
death benefit, if applicable.
(ii) PSOB Program disability benefit, if applicable.
(c) if Alternative Calculation is selected, see
Attachment 2 for the list.
(Note:
a surviving dependent who is not the child of an individual
who died as a direct result of a covered injury can
only be paid under the Alternative Calculation).
Category
of Eligibility Required Documentation
Surviving Beneficiary
[
] Surviving individual who is the beneficiary in
the most recent life insurance policy of the individual
who died as a direct result of a covered injury.
I.
Eligibility documentation
- All
eligibility documentation required for the smallpox
vaccine recipient (see A1 above in the Documentation
Checklist) or who was a vaccinia contact (see A2
above in the Documentation Checklist).
- Medical
documentation that the individual died as a direct
result of a covered injury.
- Legal
documentation
(a) A death certificate for the individual who died
as a direct result of a covered injury. If a death
certificate is not available, other documentation
of that individual’s death; and
(b) A copy of the deceased individual’s most recent
life insurance policy naming you as the beneficiary.
II.
Benefits documentation
(a)
Public Safety Officers’ Benefits (PSOB) Program
death benefit, if applicable.
(b) PSOB Program disability benefit, if applicable.
Category
of Eligibility Required Documentation
Surviving Parent or Parents
[
] Surviving parent or parents of an individual who
died as a direct result of a covered injury.
I.
Eligibility documentation
- All
eligibility documentation required for the smallpox
vaccine recipient (see A1 above
in the Documentation Checklist) or who was a
vaccinia contact (see A2 above in
the Documentation Checklist).
- Medical
documentation that the individual died as a direct
result of a covered injury.
- Legal
documentation
(a) A death certificate for the individual who died
as a direct result of a covered injury. If a death
certificate is not available, other documentation
of that individual’s death; and
(b) A birth certificate of the deceased individual
that shows that you were the parent(s). If the birth
certificate does not establish you a parent, other
documentation of the parent/child relationship.
II.
Benefits documentation
(a)
Public Safety Officers’ Benefits (PSOB) Program
death benefit, if applicable.
(b) PSOB Program disability benefit, if applicable.
[
] Legal guardian (e.g. grandparent) of deceased, eligible
minor. I. Eligibility documentation
- All
eligibility documentation required for the smallpox
vaccine recipient (see A1 above in the Documentation
Checklist) or who was a vaccinia contact (see A2
above in the Documentation Checklist).
- Medical
documentation that the individual died as a direct
result of a covered injury.
- Legal
documentation
(a) A death certificate for the individual who died
as a direct result of a covered injury. If a death
certificate is not available, other documentation
of that individual’s death; and
(b) Documentation that establishes the legal guardianship.
II.
Benefits documentation
(a)
Public Safety Officers’ Benefits (PSOB) Program
death benefit, if applicable.
(b) PSOB Program disability benefit, if applicable.
Category
of Eligibility Required Documentation
C. Personal Representatives of Estates
of Smallpox Vaccine Recipients or Vaccinia Contacts.
The estates may be eligible for medical benefits
and/or lost employment income benefits that would
have been paid to a deceased, injured smallpox vaccine
recipient or deceased, injured vaccinia contact.
[
] Representative of the estate of deceased smallpox
vaccine recipients or vaccinia contacts who died
prior to receiving full benefit by the SVIC Program.
I.
Eligibility documentation
- All
of the eligibility documentation required of individual
whose estate you represent (see Section
A1 or Section A2 above in
the Documentation Checklist).
- Legal
documentation
(a) A death certificate for the eligible individual,
or other documentation of that individual’s death;
and
(b) The deceased individual’s will or other documentation
that you represent the estate of the deceased individual.
II.
Benefits Documentation
All of the benefits documentation required of the
individual whose estate you represent (see Section
A1 or Section A2 ).
Category
of Eligibility Required Documentation
D. Personal Representatives
[
] Personal Representatives: Personal representatives
may act on behalf of any individual who may be eligible
to receive payment under the Act.
- In all
cases, the personal representative must submit all
documentation required for the eligible individual.
In those
cases in which the eligible individual does not have
the legal capacity to receive payment under the Act,
a personal representative may receive payment for
a legally incompetent individual by submitting the
following written documentation:
- Proof
showing the eligible individual does not have the
legal capacity to receive payment under the Act
(e.g., a birth certificate showing that the eligible
individual is a minor or other documentation showing
that the eligible individual is legally incompetent);
and
- For
legal guardians, documentation showing that you
have the authority to receive payment for the eligible
individual (e.g., proof of legal guardianship, or,
if the legal guardian is a parent, the birth certificate).
ATTACHMENT
1
Description of Eligibility Documentation
A
smallpox vaccine recipient must receive the
smallpox vaccine under a Plan during the period of
the Secretary’s Declaration (January 24, 2003 through
January 23, 2004, subject to change). The Request
Form must be submitted within 1 year of the smallpox
vaccination.
A
vaccinia contact must document that he or
she contracted vaccinia during the period of the Secretary’s
Declaration or no later than 30 days after the end
of the Declaration Period. The Request Form must be
submitted within two years of the first symptom.
The following
is a description of the documentation that requesters
must submit to the Smallpox Vaccine Injury Compensation
(SVIC) Program in order for the Secretary to determine
eligibility.
1.
Certification documentation. In addition
to the Request Form, the SVIC Program requires documentation
demonstrating that the smallpox vaccine recipient
identified in a Request Form:
- is a
health care worker, law enforcement officer, firefighter,
security personal, emergency medical personal, other
public safety personal, or support personal for
such occupational specialties who has volunteered
and been selected to be a member of a smallpox emergency
response plan prior to the time at which the Secretary
publicly announces that an active case of smallpox
has been identified within or outside of the United
States and that the requester is or will be functioning
in a role identified in a smallpox emergency response
plan; and
- was
administered a smallpox vaccine pursuant to an approved
smallpox emergency response plan during the effective
period of the Declaration.
Requesters
may use the Certification
Form developed for the Program
2.
Medical records necessary to establish that a covered
injury was sustained. In order to establish
that a smallpox vaccine recipient or vaccinia contact
sustained a
covered injury, a requester must submit the following
medical records:
- all
physician, clinic, or hospital outpatient medical
records documenting medical visits, consultations,
and test results that occurred on or after the date
of the smallpox vaccination or exposure to vaccinia;
and
- all
inpatient hospital medical records, including the
admission history and physical examination, the
discharge summary, all physician subspecialty consultation
reports, all progress notes, and all test results
that occurred on or after the date of the smallpox
vaccination or exposure to vaccinia.
- If the
smallpox vaccine recipient’s injury relates to the
administration of cidofovir or its derivatives or
vaccinia immune globulin (VIG), and not the smallpox
vaccine, documentation demonstrating that the smallpox
vaccine recipient was administered such a covered
countermeasure during the effective period of the
Declaration.
A requester
may submit additional medical documentation that he
or she believes will support the Request Package.
Although generally not required if a Table injury
was sustained, a requester may need to introduce additional
medical documentation or scientific documentation
in order to establish that an injury was caused by
a covered countermeasure (including the smallpox vaccine)
or vaccinia contracted through accidental vaccinia
inoculation.
If certain
medical records listed above are unavailable to the
requester after he or she has made reasonable efforts
to obtain the records, the requester must submit a
statement describing the reasons for the records=
unavailability and the efforts he or she has taken
to obtain the records. The Secretary has the discretion
to accept such a statement in place of the unavailable
medical records. In this circumstance, the Secretary
may require an authorization from the requester (or
his or her representative) to try to obtain the records
on his or her behalf.
In certain
circumstances, the Secretary may require additional
medical records to make a determination that a covered
injury was sustained (e.g., medical records prior
to the date of vaccination or accidental vaccinia
exposure) or may determine that certain records described
above are not necessary for an eligibility determination
(e.g., records that are duplicative of other records
submitted). If the Program requests additional medical
records (or information) from a requester's health
care practitioner, then the requester may use a release
form in order to have the medical records sent directly
to the Program.
ATTACHMENT
2
Description
of Benefits Documentation
1. Documentation an eligible
requester seeking medical benefits must submit. A
requester deemed eligible by the Secretary who seeks
payment or reimbursement for medical services or items
must submit the following:
- List
of Third-party Payors. The requester must
submit a list of all third-party payors that may
have an obligation to pay for or provide any medical
services or items for which payment or reimbursement
is being sought under this Program. Such third-party
payors may include, but are not limited to, health
maintenance organizations, health insurance companies,
Medicare, Medicaid, and other entities obligated
to provide medical services or items or recompense
individuals for medical expenses. Such a list must
include the individual's account numbers and other
applicable information. If the requester knows of
no such third-party payor, he or she must certify
to that fact. If the requester becomes aware that
a third-party payor may have such an obligation,
the requester must inform the Secretary within 10
business days of becoming aware of this information.
- Documents
for Medical Services or Items Provided in the Past.
A
requester seeking payment or reimbursement for medical
services or items provided in the past must submit
an itemized statement from each health care entity
(e.g., clinic, hospital, doctor, or pharmacy) and
third-party payor listing the services or items
provided to diagnose or treat the covered injury
or its health complications and the amounts paid
or expected to be paid by third parties for such
services or items (e.g., an Explanation of Benefits
from the individual's health insurance company).
If no third-party payor has an obligation to pay
for or provide such services or items, the requester
must certify to that fact and submit an itemized
list of the services or items provided (including
the total cost of such services or items). To assist
the Secretary in making a determination as to whether
such services or items were reasonable and necessary
to diagnose or treat a covered injury or its health
complications, the requester may submit, in addition
to the required medical records, documentation showing
that a health care practitioner prescribed or recommended
such services or items. The medical records must
support the requested services and items.
- Documents
for Medical Services and Items Expected to be Provided
in the Future. A requester seeking payments
for medical services or items expected to be provided
in the future must submit a statement from one or
more health care practitioner(s) (e.g., a treating
neurologist for neurologic issues and a treating
cardiologist for cardiologic issues) describing
those services and items that appear likely to be
needed to diagnose or treat the covered injury or
its health complications in the future. The medical
records must support the requested services and
items. A requester must submit documentation, if
available, concerning the likely cost of, and the
amount expected to be paid by third-party payors
for, such services or items.
2.
Documentation an eligible requester seeking benefits
for lost employment income must submit. A
requester deemed eligible by the Secretary who seeks
benefits for lost employment income from the Program
must submit, in addition to the documentation submitted
under subpart F, documentation describing:
- The
number of days (including partial days) of work
missed by the smallpox
vaccine recipient or vaccinia contact as a result
of the covered injury or its health complications
for which employment income was lost (e.g., time
sheet from pay period reflecting work days missed).
Days for which an individual used leave in order
to be paid for lost work will be considered days
of work for which employment income was received
(unless the individual's employer restores the leave
that was used by putting the individual in the same
position as if he or she had not used leave).
- The
smallpox vaccine recipient or vaccinia contact's
gross earned employment
income at the time the covered injury was sustained
(e.g., the individual's most recent Federal tax
return or a pay stub from the time of the covered
injury)
- Whether
the smallpox vaccine recipient or vaccinia contact
had one or more dependents at the time the covered
injury was sustained (e.g., the individual's most
recent Federal tax return); and
- All
third-party payors that have paid for or that may
be required to pay the requester benefits for loss
of employment income or provide disability and retirement
benefits for which payment or reimbursement is being
sought under this Program (e.g., State workers=
compensation programs, disability insurance programs,
etc.). A requester must submit documentation, if
available, concerning the amount of such payments
or benefits expected to be paid by third-party payors.
If the requester knows of no such third-party payor,
he or she must certify to that fact. If, at any
time, the requester becomes aware that a third-party
payor may have such an obligation, the requester
must inform the Secretary within 10 business days
of becoming aware of this information.
3.
Documentation an eligible requester seeking a death
benefit must submit. A requester deemed an
eligible survivor by the Secretary who seeks a death
benefit under the Standard Calculation must submit
a certification informing the Secretary whether a
disability or death benefit was paid under the PSOB
Program with respect to the deceased smallpox vaccine
recipient or vaccinia contact. If such a benefit(s)
was provided, the requester must submit documentation
showing the amount of the benefit(s) provided by the
PSOB Program. If no such benefits were provided, the
certification must explain whether any survivors are
eligible for a death benefit under the PSOB Program
and, if so, whether death benefits have been sought
under the PSOB Program.
A representative
seeking a death benefit under the Alternative Calculation
on behalf of a dependent requester younger than the
age of 18 deemed an eligible survivor by the Secretary
must submit the following:
- Documentation
showing that the deceased smallpox vaccine recipient
or vaccinia contact is survived by one or more dependents
younger than the age of 18. Such documentation must
show the date of birth of all such dependents (e.g.,
copies of birth certificates);
- A written
selection on the Request Form by each legal guardian,
on behalf of all of the dependents of this section
for whom he or she is the legal guardian, to receive
proportional death benefits under the Alternative
Calculation, in place of proportional benefits available
under the Standard Calculation.
- Documentation
showing that the requester is the legal guardian
of all of the dependents. If multiple dependents
have different legal guardians, the legal guardian
of each dependent(s) must submit such documentation.
- Documentation
showing the deceased smallpox vaccine recipient
or vaccinia contact's gross earned employment income
at the time the covered injury was sustained (e.g.,
the decedent's most recent Federal tax return or
a pay stub from the time of the covered injury);
and
- A description
of all third-party payors that have paid for or
that may be required to pay for the benefits described
in the rule. This description must include the amount
of such benefits that have been paid or that may
be authorized to be paid in the future. If the representative
knows of no such third-party payor, he or she must
certify to that fact. If, at any time, the representative
becomes aware that a third-party payor may have
such an obligation, he or she must inform the Secretary
within 10 business days of becoming aware of this
information.
ATTACHMENT
3
Description of the Calculation of Benefits
Eligible
requesters may be eligible for medical benefits, lost
income benefits, or death benefits. The follow is
a description of the calculation of the different
kinds of benefits.
I.
Calculation of medical benefits. In calculating
medical benefits, the Secretary will take into consideration
all reasonable costs for those medical items and services
that are reasonable and necessary to diagnose or treat
a requester's covered injury or its health complications.
The Secretary will consider and may rely upon benefits
documentation submitted by the requester (e.g., bills,
Explanation of Benefits, and cost-related documentation
to support the expenses relating to the covered injury
or its health complications). The Secretary will make
such payments only to the extent that such costs were
not, and will not be, paid by any third-party payor.
There are no caps on medical benefits that may be
provided under the Program.
II.
Calculation of benefits for lost employment income.
Primary
Calculation. Benefits under this section
may be paid for days of work lost as a result of a
covered injury or its health complications if the
requester lost employment income for the lost work
days. A requester's use of paid leave for lost work
days will not be considered days of lost employment
income.
The Secretary will calculate the rate of benefits
to be paid based on the requester's employment income,
which includes income from self-employment, at the
time he or she sustained the covered injury.
- For
a requester with no dependents at the time the covered
injury was sustained, the benefits are 66 2/3% of
the requester's employment income at the time the
covered injury was sustained.
- For
a requester with one or more dependents at the time
the covered injury was sustained, the benefits are
75% of the requester's employment income at the
time the covered injury was sustained; and In the
case of a requester who is a minor, the Secretary
may pay and calculate the payment of benefits for
lost employment income in accordance with the FECA
Program.
Adjustment
for Consumer Price Index. The benefits for
lost employment income paid under the Program will
be indexed to the Consumer Price Index on an annual
basis.
Limitations
on benefits paid. The Secretary will reduce
the benefits calculated, according to the following
limitations:
- Annual
Limitation. The maximum amount that a requester
can receive in any one
year in benefits for lost employment income under
this Program is $50,000
- Lifetime
Limitation. The maximum amount that a requester
can receive during his or her lifetime in benefits
for lost employment income under this Program is
the amount of death benefits that may be paid to
survivors. However, this lifetime cap does not apply
in the event that the Secretary determines that
the requester has a covered injury (or injuries)
meeting the definition of Adisability@ in section
216(i) of the Social Security Act, 42 U.S.C. 416(i);
and
- Number
of Lost Work Days. A requester will be
compensated for ten or more days of work lost if
he or she lost employment income for those days
as a result of the covered injury (or its health
complications). If the number of days of lost employment
income due to the covered injury (or its health
complications) is fewer than ten, the Secretary
will reduce the number of lost work days by five
days. If the requester lost employment income for
a period of 5 days or fewer, no benefits for lost
employment income will be paid. Lost work days do
not need to be consecutive.
Reductions
for other coverage. From the amount of benefits
calculated, the Secretary will make reductions:
- for
all payments made, or expected to be made in the
future, to the requester for compensation of lost
employment income or disability or retirement benefits,
by any third-party payor in relation to the covered
injury or its health complications; and
- so that
the total amount of benefits for lost employment
income paid to a requester under this Program, together
with the total amounts paid (or payable) by third-party
payors, as described above, do not exceed 66 2/3%
(or 75%, if the requester had at least one dependent
at the time the covered injury was sustained) of
the requester's employment income at the time of
the covered injury. If a requester receives a lump-sum
payment from any third-party payor, under any obligation
described above, the Secretary shall deem such a
payment to be received over a period of years, rather
than in a single year. The Secretary has discretion
as to how to apportion such payments over multiple
years
Termination
of Payments. The Secretary will not pay benefits
for lost employment
income after the requester reaches the age of 65.
III.
Calculation of Death Benefits. Of all payment
methods, this has the most complexities. Variables
include the hierarchy of survivors, payments for dependents
under the age of 18, eligibility for death benefits
under the PSOB, and, in certain cases, the amount
of lost employment income benefits that the smallpox
vaccine recipient received under the SVIC Program.
Therefore, the Program suggests that requesters read
this section carefully and refer to the administrative
regulations that govern the operations of the Program.
Definitions.
For purposes of this section:
- deceased
individual means an otherwise eligible deceased
smallpox vaccine recipient or vaccinia contact;
and
- dependents
means a deceased individual's surviving eligible
dependents younger than 18 years of age (at the
time of filing and payment).
A.
Standard calculation of death benefits. The
maximum death benefit available is the amount of the
comparable death benefit calculated under the PSOB
Program in the same fiscal year, except as follows:
- If death
benefits under the PSOB Program are reduced based
on a limitation on appropriations, death benefits
will not be similarly reduced; and
- The
death benefit paid will be reduced by the total
amount of benefits for lost employment income paid
under this Program to the deceased individual during
his or her lifetime.
No death
benefit will be paid under this paragraph if a death
benefit has been paid, or if survivors are eligible
to receive a death benefit, under the PSOB Program
with respect to the deceased individual.
No death
benefit will be paid if a disability benefit has been
paid under the PSOB Program with respect to the deceased
individual. However, if the PSOB Program disability
benefit paid was reduced because of a limitation on
appropriations, a death benefit will be available
to the extent necessary to ensure that the total amount
of disability benefits paid under the PSOB Program
to eligible survivor(s), together with the amount
of death benefits, equals the amount of the PSOB death
benefit.
Death benefits
under the Standard Calculation will be paid a lump
sum.
B.
Alternative Calculation of death benefits.
This option is available to surviving dependents younger
than the age of 18. If a deceased smallpox vaccine
recipient or vaccinia contact had at least one dependent
who is younger than the age of 18, the legal guardian
of all such dependents can request benefits under
the alternative calculation. To receive such a benefit,
the legal guardian(s) of all such dependents, on behalf
of all of them, must file an election (included on
the Request Form in Section D).
General Information. Payments made
under the Alternative Calculation will be made to
all of the dependents. Although payments under the
Alternative Calculation are based on the deceased
individual's employment income at the time he or she
sustained the covered injury, benefits under this
paragraph are death benefits and do not represent
benefits for lost employment income.
Election.
Before a payment will be approved, the legal guardian(s)
of the dependents must elect, on behalf of all the
dependents, to receive a death benefit under this
paragraph. If such an election is approved by the
Secretary, these dependents will be paid the death
benefit in lieu of the proportionate share of benefits
that would otherwise be available to them under the
Standard Calculation.
Amount
of Payments. The maximum death benefit available
under this paragraph is 75% of the deceased individual's
income (including income from self-employment) at
the time he or she sustained the covered injury that
resulted in death, indexed to the Consumer Price Index
on an annual basis, except as follows:
- The
maximum payment of death benefits that may be made
to the aggregate of the dependents in any one year
is $50,000.
- All
payments made under this paragraph will stop once
the youngest of the dependents reaches the age of
18.
Reductions
for other coverage. The total amount of death
benefits will be reduced so that the total amount
of payments made (or expected to be made) under obligations
described in Attachment 2
under the documentation for Lost Income Benefits,
together with the death benefits paid under the Alternative
Calculation, is not greater than the amount of lost
employment income payments.
The amount
of death benefits will be reduced for all payments
made, or expected to be paid in the future, by any
third-party payor for:
- compensation
for the deceased individual's loss of employment
income;
- death
benefits in relation to the deceased individual
(including, but not limited to, death benefits under
the PSOB Program); and
- disability,
retirement, or life insurance benefits on behalf
of the dependents (including, but not limited to,
disability benefits on behalf of the dependents
under the PSOB Program).
In calculating
such reductions, the Secretary will deem any lump-sum
payment made by a third-party payor under any obligation
, as received over a period of years, rather than
in a single year. The Secretary has discretion as
to how to apportion such payments over multiple years.
Timing
of Payments. Payments made under the Alternative
Calculation will be made on an annual basis, beginning
at the time of the initial payment. In the year in
which the youngest dependent reaches the age of 18,
payments under this section may be paid on a pro rata
basis for the period of time before that dependent
reaches the age of 18.
IV.
Payment of all benefits. The Secretary may
pay any benefits under this Program through lump-sum
payments.
If the
Secretary determines that there is a reasonable likelihood
that the payments of benefits to a requester will
be required for a period in excess of one year from
the date the requester is deemed eligible for such
benefits, the Secretary may make a lump-sum payment,
purchase an annuity or medical insurance policy, or
execute an appropriate structured settlement agreement,
provided that such payment, annuity, policy, or agreement
is actuarially determined to have a value equal to
the present value of the projected total amount of
benefits that the requester is eligible to receive.
Any payment of benefits made over a period of multiple
years will be indexed to the Consumer Price Index
on an annual basis.
Lump sum
payments will be made through an electronic funds
transfer to an account of the requester. However,
if the requester is a minor or a legally incompetent
adult, the legal guardian must establish a guardianship
or conservatorship of the estate account with court
oversight, in accordance with State law, and payment
will be made to that account.
The Secretary
may make interim payments of benefits under this Program,
even before he makes a final determination as to the
total type and total amount of benefits that will
be paid. The Secretary will only make an interim payments
of benefits after he has calculated that type or subset
of benefits. For example, the Secretary may, in certain
cases, make an interim payment of medical benefits
that have been calculated before a final determination
on benefits for lost employment income is completed,
or of past medical benefits that have been calculated
before a final calculation of future medical benefits
is completed. Any payments made on an interim basis
will not entitle a requester to seek reconsideration
of the Secretary's decision on these benefits until
the Secretary makes a complete benefits determination.
The Secretary's
right to recover benefits paid under this Program
from third-party payors.
Upon payment
of benefits under this Program, the Secretary will
be subrogated to the rights of the requester and may
assert a claim against any third-party payor with
a legal or contractual obligation to pay for (or provide)
such benefits and may recover from such third-party
payor(s) the amount of benefits paid up to the amount
of benefits the third-party payor has or had an obligation
to pay for (or provide). The circumstances in which
the Secretary may assert this right include those
in which the Secretary pays benefits under this Program
to a requester before a final decision is made that
a third-party payor has an obligation to pay such
benefits to the requester. Requesters receiving benefits
under this Program (or their representatives) shall
assist the Secretary in recovering such benefits.
*
Under the Secretary’s Declaration, published
in the Federal Register on January 28, 2003, this
period is from January 24, 2003 through January 23,
2007. This period is subject to change.
Contact:
smallpox@hrsa.gov
or 1-888-496-0338
--------------------------------------------------------------------------------
Health
Resources and Services Administration
U.S. Department of Health and Human Services
Parklawn Building
5600 Fishers Lane
Rockville, Maryland 20857
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