[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

ICR 202402-0920-004

OMB: 0920-0891

Federal Form Document

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document Name	Status
Form 0920-0891 Designated Representative Revocation Form Form and Instruction	Unchanged
Form 0920-0891 Designated Representative Revocation Form Form and Instruction	Unchanged
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction	Modified
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction	Modified
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction	Modified
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction	Modified
Form 0920-0891 Member Satisfaction Survey Form and Instruction	Unchanged
Form 0920-0891 Member Satisfaction Survey Form and Instruction	Unchanged
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction	Unchanged
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction	Unchanged
HIPAA Authorization to Release Information Form and Instruction	Unchanged
HIPAA Authorization to Release Information Form and Instruction	Unchanged
Designated Representative Form and Instruction	Unchanged
Designated Representative Form and Instruction	Unchanged
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form	Unchanged
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form	Unchanged
Survivor Eligibility Application Form and Instruction	Unchanged
Survivor Eligibility Application Form and Instruction	Unchanged
Pentagon / Shanksville Responder Form and Instruction	Unchanged
Pentagon / Shanksville Responder Form and Instruction	Unchanged
General Responder Eligibility Application Form and Instruction	Unchanged
General Responder Eligibility Application Form and Instruction	Unchanged
FDNY Responder Eligibility Application Form and Instruction	Unchanged
FDNY Responder Eligibility Application Form and Instruction	Unchanged
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change	2024-02-12
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change	2024-02-12
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document	2022-01-06
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document	2022-01-06
App X Survivor 90 Day Suspend Letter.docx Supplementary Document	2022-01-06
App X Survivor 90 Day Suspend Letter.docx Supplementary Document	2022-01-06
App W 60 Day Suspend Letter.docx Supplementary Document	2022-01-06
App W 60 Day Suspend Letter.docx Supplementary Document	2022-01-06
App V 30 Day Suspend Letter.docx Supplementary Document	2022-01-06
App V 30 Day Suspend Letter.docx Supplementary Document	2022-01-06
App U Initial Request for Additional Information.docx Supplementary Document	2022-01-06
App U Initial Request for Additional Information.docx Supplementary Document	2022-01-06
App ZZ Disenrollment Letter.docx Supplementary Document	2022-01-06
App ZZ Disenrollment Letter.docx Supplementary Document	2022-01-06
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document	2022-01-06
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document	2022-01-06
App QQ Certification Denial Letter and Appeal.docx Supplementary Document	2022-01-06
App QQ Certification Denial Letter and Appeal.docx Supplementary Document	2022-01-06
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document	2022-01-06
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document	2022-01-06
App AAA Decert Letter Template Admin Error.docx Supplementary Document	2022-01-06
App AAA Decert Letter Template Admin Error.docx Supplementary Document	2022-01-06
App DDD Summary of Forms and Changes.docx Supplementary Document	2022-01-06
App DDD Summary of Forms and Changes.docx Supplementary Document	2022-01-06
SSB-Update-91321.docx Supporting Statement B	2022-01-06
SSB-Update-91321.docx Supporting Statement B	2022-01-06
SSA-Update-091321.docx Supporting Statement A	2022-01-06
SSA-Update-091321.docx Supporting Statement A	2022-01-06
60d FRN published.pdf Supplementary Document	2022-01-06
60d FRN published.pdf Supplementary Document	2022-01-06
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document	2018-10-09
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document	2018-10-09
App Y-10. NF PA3 Nucala.pdf Supplementary Document	2018-10-09
App Y-10. NF PA3 Nucala.pdf Supplementary Document	2018-10-09
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document	2018-10-09
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document	2018-10-09
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document	2018-10-09
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document	2018-10-09
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document	2018-10-09
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document	2018-10-09
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document	2018-10-09
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document	2018-10-09
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document	2018-10-09
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document	2018-10-09
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document	2018-10-09
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document	2018-10-09
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document	2018-10-09
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document	2018-10-09
App Y-2. PA3 Renewal Form.pdf Supplementary Document	2018-10-09
App Y-2. PA3 Renewal Form.pdf Supplementary Document	2018-10-09
App Y-1. General PA3 Form.pdf Supplementary Document	2018-10-09
App Y-1. General PA3 Form.pdf Supplementary Document	2018-10-09
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document	2018-09-20
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document	2018-09-20
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document	2018-09-20
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document	2018-09-20
App SS Summary of Forms and Changes_100918.docx Supplementary Document	2018-10-09
App SS Summary of Forms and Changes_100918.docx Supplementary Document	2018-10-09
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document	2018-09-20
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document	2018-09-20
App PP Disenrollment and Decert Template.docx Supplementary Document	2018-09-20
App PP Disenrollment and Decert Template.docx Supplementary Document	2018-09-20
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document	2018-09-20
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document	2018-09-20
App JJ - Translated 180 Day Request for Information.docx Supplementary Document	2018-09-20
App JJ - Translated 180 Day Request for Information.docx Supplementary Document	2018-09-20
App II - Translated 90 Day Request for Information.docx Supplementary Document	2018-09-20
App II - Translated 90 Day Request for Information.docx Supplementary Document	2018-09-20
App HH - Translated 60 Day Request for Information.docx Supplementary Document	2018-09-20
App HH - Translated 60 Day Request for Information.docx Supplementary Document	2018-09-20
App GG - Translated 30 Day Request for Information.docx Supplementary Document	2018-09-20
App GG - Translated 30 Day Request for Information.docx Supplementary Document	2018-09-20
App FF - Translated Initial Request for Information.docx Supplementary Document	2018-09-20
App FF - Translated Initial Request for Information.docx Supplementary Document	2018-09-20
App EE IRB Determination.pdf Supplementary Document	2018-09-20
App EE IRB Determination.pdf Supplementary Document	2018-09-20
App DD-1 60-day FRN 05112018.pdf Supplementary Document	2018-09-20
App DD-1 60-day FRN 05112018.pdf Supplementary Document	2018-09-20
App X Prior Authorization Form_Transplant.pdf Supplementary Document	2018-09-20
App X Prior Authorization Form_Transplant.pdf Supplementary Document	2018-09-20
App W Prior Authorization Form_Dental.pdf Supplementary Document	2018-09-20
App W Prior Authorization Form_Dental.pdf Supplementary Document	2018-09-20
App V Prior Authorization Form_Standard.pdf Supplementary Document	2018-09-20
App V Prior Authorization Form_Standard.pdf Supplementary Document	2018-09-20
App U WTC6 Medication Request.pdf Supplementary Document	2018-09-20
App U WTC6 Medication Request.pdf Supplementary Document	2018-09-20
App T WTC_5 Code or Procedure Request.pdf Supplementary Document	2018-09-20
App T WTC_5 Code or Procedure Request.pdf Supplementary Document	2018-09-20
App Q 180 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App Q 180 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App P 90 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App P 90 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App O 60 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App O 60 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App N 30 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App N 30 Day Letter Requesting Information.docx Supplementary Document	2018-09-20
App M Initial Letter Requesting Information.docx Supplementary Document	2018-09-20
App M Initial Letter Requesting Information.docx Supplementary Document	2018-09-20
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document	2018-09-20
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document	2018-09-20
Appendix A Legislation.docx Supplementary Document	2014-12-18
Appendix A Legislation.docx Supplementary Document	2014-12-18

IC Document Collections

IC ID	Document Title	Status
251030	Designated Representative Revocation Form Form and Instruction	Unchanged
251030	Designated Representative Revocation Form Form and Instruction	Unchanged
251023	WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction	Modified
251023	WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction	Modified
251018	WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction	Modified
251018	WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction	Modified
251017	Member Satisfaction Survey Form and Instruction	Unchanged
251017	Member Satisfaction Survey Form and Instruction	Unchanged
233098	Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction	Unchanged
233098	Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction	Unchanged
233095	HIPAA Authorization to Release Information Form and Instruction	Unchanged
233095	HIPAA Authorization to Release Information Form and Instruction	Unchanged
218098	Designated Representative Form and Instruction	Unchanged
218098	Designated Representative Form and Instruction	Unchanged
218096	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form	Unchanged
218096	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form	Unchanged
214326	Survivor Eligibility Application Form and Instruction	Unchanged
214326	Survivor Eligibility Application Form and Instruction	Unchanged
214325	Pentagon / Shanksville Responder Form and Instruction	Unchanged
214325	Pentagon / Shanksville Responder Form and Instruction	Unchanged
214324	General Responder Eligibility Application Form and Instruction	Unchanged
214324	General Responder Eligibility Application Form and Instruction	Unchanged
214323	FDNY Responder Eligibility Application Form and Instruction	Unchanged
214323	FDNY Responder Eligibility Application Form and Instruction	Unchanged

ICR Details