WTC Health Program HIPAA Authorization for Deceased Individuals

[NIOSH] 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⚠️ Notice: This information collection may be referencing outdated material.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
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
0920-0891 WTC Health Program HIPAA Authorization - Deceased Indivi App O WTCHP HIPAA Authorization for Deceased Individuals DRAFT.docx Form and Instruction
0920-0891 WTC Health Program HIPAA Authorization - Deceased Indivi App O WTCHP HIPAA Authorization for Deceased Individuals DRAFT.docx Form and Instruction
0920-0891 HIPAA Authorization for Disclosures Regarding Deceased I App-O-WTCHP-HIPAA-Authorization-for-Deceased-Individuals-updated2024.pdf Form and Instruction
0920-0891 HIPAA Authorization for Disclosures Regarding Deceased I App-O-WTCHP-HIPAA-Authorization-for-Deceased-Individuals-updated2024.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	WTC Health Program HIPAA Authorization for Deceased Individuals	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	0920-0891	WTC Health Program HIPAA Authorization - Deceased Individuals	App O WTCHP HIPAA Authorization for Deceased Individuals DRAFT.docx	NA	Yes	Yes	Fillable Fileable
Form and Instruction	0920-0891	HIPAA Authorization for Disclosures Regarding Deceased Individuals	App-O-WTCHP-HIPAA-Authorization-for-Deceased-Individuals-updated2024.pdf	N/A	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records	FR Citation: 76 FR 34706

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

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.