Initial Request - Additional Information

RE:

Dear:

I am writing to let you know that the application you submitted to enroll in the World Trade Center (WTC) Health Program remains incomplete. It is important to know that we cannot process your application and make an enrollment decision until you have submitted all required information.

You currently have submitted the following items with your enrollment application:

{processor will choose one selection or multiple selections from the list below}

In addition to the above item(s) that you have already submitted, the WTC Health Program must have the following item(s) in order to complete your enrollment application:

{processor to choose one selection or multiple selections from the list below}

The item(s) listed above will complete your application and allow the WTC Health Program to make an enrollment decision for your application. The remaining items for your application may be faxed to 1-877-646-5308, or mailed to:

World Trade Center Health Program

PO Box 7000

Rensselaer, NY 12144

If you have questions about the WTC Health Program or need any assistance in obtaining the required information we have requested:

Please call your Enrollment Center Specialist at __________. If you are unable to reach your Enrollment Center Specialist; call us at 1-888-WTC-HP4U (1-888-982-4748), Monday through Friday, 9 AM to 5 PM EST or visit the WTC Health Program website at: http://www.cdc.gov/wtc

Sincerely,

Enrollment Center Specialist

World Trade Center Health Program

The following types of documentation will be accepted:

GENERAL RESPONDER (other than NYPD/PAPD):

• Letter from employer or volunteer organization that acknowledges WTC duties, including: location, dates, and times associated with the responder work. Letter must be signed.

• Signed, notarized affidavits from a third party stating knowledge of where and when you worked as a Responder, and what Responder work you performed

• Health Registry Survey, which may be obtained by calling (866) 692-9827 (must not be altered).

• 3rd party letter written under penalty of perjury, which confirms your WTC duties, including: location, dates, and times associated with responder work. This letter can be written by a family member, spouse, friend, or anyone who may provide an accurate account of your participation. Their signature is required for this letter.