Decertification Letter Notification Health Condition

WTC Health Program

PO Box 7002

Rensselaer, NY 12144

Name

Address

Address

Re: 911XXXXXX

<Date>

Dear (Insert Member Name):

Thank you for your participation in the World Trade Center (WTC) Health Program. This letter is to inform you that your health condition, [INSERT HEALTH CONDITION], is not eligible for certification as a WTC-related health condition, as discussed further below.

In order to have a health condition remain certified as WTC-related, the condition must be included on the List of WTC-Related Health Conditions and your 9/11 exposure must be determined to have been substantially likely to be a significant factor in aggravating, contributing to, or causing your health condition. In making this assessment, the WTC Health Program considers a number of factors, including your exposure to airborne toxins or other adverse conditions resulting from the 9/11 terrorist attacks, the type of symptoms you experienced, and when those symptoms began in relation to your exposure.

Based upon review of information submitted by your WTC Health Program Clinical Center of Excellence (CCE), you were incorrectly certified for the following condition, (Insert Health Condition), due to an administrative error.

We apologize for the inconvenience this error may have caused. The WTC Health Program has corrected this error, updated your member record, and decertified the following condition:

Date of Original Certification	Condition Category on List of WTC-Related Health Conditions*	Certification Category or Injury
(Effective Date)		(Insert Health Condition)

* As listed in the James Zadroga 9/11 Health and Compensation Act of 2010 and/or 42 C.F.R. § 88.15

You are still enrolled as a certified-eligible (Choose: RESPONDER/SURVIVOR), which means that you remain eligible for monitoring and treatment benefits for the following certified health condition(s):

Date of Original Certification	Condition Category on List of WTC-Related Health Conditions*	Certification Category or Injury
(Effective Date)	(Insert Zadroga Term)	(Insert Health Condition)

* As listed in the James Zadroga 9/11 Health and Compensation Act of 2010 and/or 42 C.F.R. § 88.15

(Insert Medically Associated Boxes, as necessary)

The WTC Health Program will only provide payment for medically necessary treatment(s) authorized by your WTC Health Program physician for your certified health condition(s) by a WTC Health Program participating provider.

If you would like more information or believe that a health condition is missing, incorrect, or should be removed, please discuss this with the (Insert CCE/NPN) at (Insert CCE/NPN contact number). If the information in this letter is correct, no further action is necessary.

If you have any other questions, you may contact the WTC Health Program at 1-888-982-4748 Monday through Friday, 9 AM to 5 PM (Eastern Time Zone).

Sincerely,

John Howard, M.D.

Administrator, World Trade Center Health Program

Copy to: Director, Clinical Center of Excellence