90-day Letter Requesting Information

Appendix P

90 Day Letter Requesting Additional Information

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

Your application to enroll in the World Trade Center (WTC) Health Program still remains incomplete.

We cannot process your application until we receive the needed information from you. If you have already received a telephone call about the needed information, this letter is meant as a reminder.

Please provide the Enrollment Center the following information at your earliest convenience:

[Specify exactly what information is needed from the applicant]

Missing information may be faxed to 1-877-646-5308, or mailed to:

WTC Health Program

PO Box 7000

Rensselaer, NY 12144

ATTENTION: If we do not receive any communication from you by [DATE 90 DAYS FROM THIS LETTER], which will be 90 days from the date of this letter, we will mark your application as "inactive."

Please be aware that unless your application is completed, your eligibility for the WTC Health Program cannot be determined. This means that at this time you are not an enrolled member of the WTC Health Program, and are not eligible for Program benefits.

If you have questions about the WTC Health Program or need any assistance in providing the information we request:

Call your Enrollment Center Specialist at [TELEPHONE NUMBER]. If you are unable to reach your Enrollment Center Specialist, call us at 1-888-982-4748, Monday through Friday, 9 AM to 5 PM (Eastern Time Zone) or visit the WTC Health Program website at: http://www.cdc.gov/wtc.

Sincerely,

[NAME]

Enrollment Center Specialist

WTC Health Program