Data form-Agreement Att A in Agreement.pdf

Description of Agreement-Attachment A

VACCINE INJURY COMPENSATION PROGRAM (VICP)

MEDICAL EXPERT PANEL (MEP)

Data Collection Form

General Instructions:

1. Type or print ALL information clearly, including Not Applicable (N/A) blanks.

2. We are requiring everyone to receive case documents via a secure mail system called SEFT. We will only send paper files on a very limited basis.

3. Please provide a telephone number or numbers where you prefer to be contacted.

Name: ____________________________________ SSN: ____________________________________

DOB: ____________________________________ Medical Specialty: ___________________________

Taxpayer Identification Number (If different from SSN):

Data Universal Number System ID Number (DUNS):

Registered in SAM: Yes / No

If yes, SAM Expiration Date: _____________________

Mailing Address:

E: Mail Address: _______________________________

Telephone Number(s):

Office: ____________________ Home: ____________________ Cell: ____________________