Designated Representative Form

Appendix LL

Designated Representative Form

Form Approved

OMB No. 0920-0891 Exp. Date XX-XX-XXXX

World Trade Center Health Program

Designated Representative Form

A designated representative is an individual whom you appoint and authorize to act on your behalf and represent your interests in the World Trade Center (WTC) Health Program. A designated representative is allowed to provide and obtain personal information regarding your application to the WTC Health Program, your care, and your membership in the Program, and may make a request or give direction to the Program regarding your eligibility, certification, or any other administrative issue under the WTC Health Program, including appeals. A designated representative can be anyone such as an attorney, family member, advocate, or friend, unless that individual's service as a representative would violate any applicable provision of law (a Federal employee may act as a representative only on behalf of the individuals specified in, and in the manner permitted by, 18 U.S.C. §§ 203 and 205ⁱ). A parent or guardian may act on behalf of a minor.

You may have appointed a healthcare proxy or assigned a healthcare power of attorney to a family member or other person so that they may obtain, use, and disclose your personal information, and/or make medical treatment decisions on your behalf. Please note that a healthcare proxy/power of attorney is different from a designated representative. A designated representative within the WTC Health Program may not make medical care (e.g., treatment) decisions on your behalf. If you have already appointed someone to act on your behalf regarding healthcare decisions and you would like for that person to also serve as your designated representative for purposes of the WTC Health Program, please complete this form.

Please note, a designated representative also differs from any attorney or licensed representative involved in any workers’ compensation or other worker-related injury or illness claim you may have.

The WTC Health Program will only recognize one designated representative at a given time, and the designated representative must be properly appointed in writing using this form. Once the designated representative has been properly appointed, the WTC Health Program will not recognize another individual as a designated representative until the appointment of the first designated representative is withdrawn in writing.

Any notice requirement of the WTC Health Program is fully satisfied if sent to the designated representative.

By designating a representative, you are authorizing the WTC Health Program to disclose your member information to the designated representative and authorizing that individual to do the following:

• Serve as your representative in all matters pertaining to your membership in the WTC Health Program; and

• Receive and/or provide information pertaining to your membership and participation in the WTC Health Program, including copies of factual and medical evidence contained in your records for the Program.

Any notice requirement of the WTC Health Program is fully satisfied if sent to the designated representative.

By designating a representative, you are authorizing the WTC Health Program to disclose your member information to the designated representative and authorizing that individual to do the following:

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0891).

• Serve as your representative in all matters pertaining to your membership in the WTC Health Program; and

• Receive and/or provide information pertaining to your membership and participation in the WTC Health Program, including copies of factual and medical evidence contained in your records for the Program.

If you would like to authorize a designated representative to act on your behalf in matters related to your WTC Health Program application and/or membership, please provide the following information:

First & Last Name of the Designated Representative ______________________________________

Your Relationship to the Designated Representative (e.g., spouse, parent, adult child, attorney)

_________________________________________________________________________________

Mailing Address of the Designated Representative:

Street: ____________________________________________ Street 2: ___________________

City: ________________________ State: ___________ Zip Code: _______________

Designated Representative’s Primary Phone: (______) _______ - ________

Please read the following statement before signing the form.

I declare that the above information is true and correct. This designation is effective on the date it is signed, and is effective until either the expiration of the WTC Health Program (when the Program is no longer funded and is unable to provide services under Title XXXIII of the Public Health Service Act) or it is specifically revoked by me in writing.

_________________________________________________ _______________________________

Printed Name WTC Health Program ID# (begins 911)

_________________________________________________

Address

_________________________________________________

Address

_________________________________________________ ____________________________

Signature Date

i An employee may represent, with or without compensation, the following: the employee (self-representation); a parent, spouse or child of the employee; or a person or estate that the employee serves as a guardian, executor, administrator, trustee or personal fiduciary. See http://www.oge.gov/Laws-and-Regulations/Statutes/18-U-S-C--§-203--Compensation-to-Members-of-Congress,-officers,-others-in-matters-affecting-the-Government/