Non-Substantive Change Request Memo [12FEB2024]

Request for Non-substantive Change

World Trade Center Health Program Enrollment, Petitions, Designated Representative/HIPAA Authorization, and Member Satisfaction

OMB Approval #0920-0891 – Expiration date 09/30/2025

Justification for Non-substantive change:

NIOSH is requesting a non-substantive change request for 0920-0891 to add updated information to the Appendix O and P. These forms are being updated to change the address from 395 E Street SW, Suite 9200 Washington, DC 20201, to the current address of 400 7th Street SW, Suite 5W, Washington D.C., 20024.

Existing documents being updated

Appendix O-WTC Health Program HIPAA Authorization for Deceased Individuals

Appendix P-WTC Health Program General HIPAA Authorization to Third Parties

The burden hours and costs will not be affected by these proposed changes.