HIPAA Authorization to Release Information

World Trade Center Health Program Enrollment, Appeals & Reimbursement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Document Name Document Type
HIPAA Authorization to Release Information Form and Instruction
HIPAA Authorization Form to Release Information App MM WTC HIPAA Form.docx Form and Instruction
HIPAA Authorization Form to Release Information App MM WTC HIPAA Form.docx Form and Instruction

Information Collection (IC) Details

IC Title:	HIPAA Authorization to Release Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	HIPAA Authorization Form to Release Information	App MM WTC HIPAA Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records HHS/CDC/NIOSH	FR Citation: 76 FR 34706

Number of Respondents: 1,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,300	1,270	30
Annual IC Time Burden (Hours)	325	317	8
Annual IC Cost Burden (Dollars)	5,915	5,778	137

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.