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another individual as a designated representative until the appointment of the first designated representative is withdrawn in writing.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/
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2024-09-12 |