Form 0920-0891 WTCHP - Application for Enrollment: Pentagon/Shanksville

WORLD TRADE CENTER HEALTH PROGRAM

Application for Enrollment: Pentagon/Shanksville Responder

Form Approved
OMB No. 0920-0891
Exp. Date XX/XX20XX

This application is for enrollment in the World Trade Center (WTC) Health Program as a Pentagon/Shanksville
Responder. A Pentagon/Shanksville Responder is an individual who performed rescue, recovery, demolition, debris
cleanup or other related services and the Pentagon crash site in Arlington, Virginia, from September 11, 2001, to
November 19, 2001; or the crash site in Shanksville, Pennsylvania from September 11, 2001, to October 3, 2001. Eligible
individuals must have been a member of a fire or police department (whether fire or emergency personnel, active or
retired), worked for a recovery or cleanup contractor, was a volunteer, was an employee of the Department of Defense or
any other Federal agency, worked for a contractor of the Department of Defense or any other Federal agency between
September 11, 2001, and September 18, 2001, or was a member of a regular or reserve component of the uniformed
services.
If you have questions, call the WTC Health Program at 1-888-982-4748 or visit www.cdc.gov/wtc. To apply online, visit
https://oasis.cdc.gov/. If you have previously applied do not submit a new application and call 1-888-982-4748
about your previous application status. Note: Enrollment in the WTC Health Program does not enroll you in other 9/11
assistance programs such as the September 11th Victim Compensation Fund.
Instructions: Please provide the following information to begin the eligibility determination process. Type or print clearly.
When marking a checkbox, use “” or “”. Incomplete or inadequate information could result in a delay processing your
application.

Personal Information
Today’s Date (mm/dd/yyyy)
Last Name

Suffix (Jr., II, III, etc.)

First Name

Middle Name

Mailing Address
City

Apt/Suite
State

Zip Code

Country

Preferred Phone Number ((xxx)xxx-xxxx)

c Cell

c Home

c Work

Secondary Phone Number ((xxx)xxx-xxxx)

c Cell

c Home

c Work

Email Address
Sex at Birth:

c Male

c Female

Date of Birth (mm/dd/yyyy)
Place of Birth (City/State/Country)
If you have ever gone by another name (e.g., maiden name, nickname) please list them below with last, first, and middle
name, as applicable. Note: you may be asked to provide proof of a legal name change (e.g., marriage certificate).

Public reporting burden of this collection of information is estimated to average 30 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).

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Application Page 1 of 15

WTC Health Program Application for Enrollment—Pentagon/Shanksville Responder

Pentagon Responders – 9/11 Experience
Please answer the following questions about your work activities and location(s) from September 11, 2001, to November
19, 2001, at the Pentagon crash site. If you were a Shanksville responder, please proceed to the Shanksville Responders
- 9/11 Experience section below.

Activities and Locations
The “Pentagon site” means any area of the land (consisting of approximately 280 acres) and improvements thereon,
located in Arlington, Virginia, on which the Pentagon Office Building, Federal Building Number 2, the Pentagon heating
and sewage treatment plants, and other related facilities are located, including various areas designated for the parking
of vehicles, vehicle access, and other areas immediately adjacent to the land or improvements previously described
that were affected by the terrorist-related aircraft crash on September 11, 2001; and those areas at Fort Belvoir in
Fairfax County, Virginia, and at the Dover Port Mortuary at Dover Air Force Base in Delaware involved in the recovery,
identification, and transportation of human remains for the incident.
Did you perform rescue, recovery, demolition, debris cleanup, or other related services at the Pentagon site of the
terrorist-related aircraft crash of September 11, 2001, from September 11, 2001, to November 19, 2001?
c Yes c No
If so, check all the boxes below that apply to your response work on or after September 11, 2001:
 I was a member of a fire or police department (whether fire or emergency personnel, active or retired)
“Police department” means any law enforcement department or agency, whether under Federal, state, or local
jurisdiction, responsible for general police duties, such as maintenance of public order, safety, or health, enforcement
of laws, or otherwise charged with prevention, detection, investigation, or prosecution of crimes.
 I worked for a recovery or cleanup contractor
 I was a volunteer
 I was an employee of the Department of Defense or any other Federal agency
 I worked for a contractor of the Department of Defense or any other Federal agency between September 11,
2001, and September 18, 2001
 I was a member of a regular or reserve component of the uniformed services
 None of the above, but I believe that I qualify for the following reason:

Please briefly describe your work duties performed on or after September 11, 2001. Include the location(s) where these
duties were performed. This information will help the WTC Health Program better understand your experience and
evaluate your supporting documentation. Note: This description does not replace the need for supporting documentation.

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Application Page 2 of 15

WTC Health Program Application for Enrollment—Pentagon/Shanksville Responder

HOURS AND TIME PERIOD
To the best of your ability, fill in the calendars below with the number of hours each day that you performed rescue,
recovery, demolition, debris cleanup, or other related services at the Pentagon site from September 11, 2001, to
November 19, 2001.
September 11 – September 30, 2001
Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

11

12

13

14

15

hours

hours

hours

hours

hours

16

17

18

19

20

21

22

hours

hours

hours

hours

hours

hours

hours

23

24

25

26

27

28

29

hours

hours

hours

hours

hours

hours

hours

30
hours
October 1 – October 31, 2001
Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

1

2

3

4

5

6

hours

hours

hours

hours

hours

hours

7

8

9

10

11

12

13

hours

hours

hours

hours

hours

hours

hours

14

15

16

17

18

19

20

hours

hours

hours

hours

hours

hours

hours

21

22

23

24

25

26

27

hours

hours

hours

hours

hours

hours

hours

28

29

30

31

hours

hours

hours

hours

November 1 - November 19, 2001
Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

1

2

3

hours

hours

hours

4

5

6

7

8

9

10

hours

hours

hours

hours

hours

hours

hours

11

12

13

14

15

16

17

hours

hours

hours

hours

hours

hours

hours

18

19

hours

hours

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Application Page 3 of 15

WTC Health Program Application for Enrollment—Pentagon/Shanksville Responder

Shanksville Responders – 9/11 Experience
This section asks questions about your work activities and location(s) from September 11, 2001, to October 3, 2001, at the
Shanksville, Pennsylvania, site. If you were a Pentagon responder, you can skip this section.

Activities and Locations
The “Shanksville, Pennsylvania site” means the property in Stonycreek Township, Somerset County, Pennsylvania,
which is bounded by Route 30 (Lincoln Highway), State Route 1019 (Buckstown Road), and State Route 1007
(Lambertsville Road); and those areas at the Pennsylvania National Guard Armory in Friedens, Pennsylvania, involved in
the recovery, identification, and transportation of human remains from the incident.
Did you perform rescue, recovery, demolition, debris cleanup, or other related services at the at the Shanksville,
Pennsylvania, site of the terrorist-related aircraft crash of September 11, 2001, from September 11, 2001, to October 3,
2001?
c Yes c No
If so, check all the boxes below that apply to your response work on or after September 11, 2001:
 I was a member of a fire or police department (whether fire or emergency personnel, active or retired)
“Police department” means any law enforcement department or agency, whether under Federal, state, or local
jurisdiction, responsible for general police duties, such as maintenance of public order, safety, or health, enforcement
of laws, or otherwise charged with prevention, detection, investigation, or prosecution of crimes.
 I worked for a recovery or cleanup contractor
 I was a volunteer
 I was an employee of the Department of Defense or any other Federal agency
 I worked for a contractor of the Department of Defense or any other Federal agency between September 11,
2001, and September 18, 2001
 I was a member of a regular or reserve component of the uniformed
 None of the above, but I believe that I qualify for the following reason:

Please briefly describe your work duties performed on or after September 11, 2001. Include the location(s) where these
duties were performed. This information will help the WTC Health Program better understand your experience and
evaluate your supporting documentation. Note: This description does not replace the need for supporting documentation.

Do not write in this space

Application Page 4 of 15

WTC Health Program Application for Enrollment—Pentagon/Shanksville Responder

HOURS AND TIME PERIOD
To the best of your ability, fill in the calendars below with the number of hours each day that you performed rescue,
recovery, demolition, debris cleanup, or other related services at the Shanksville, Pennsylvania site from September 11,
2001, to October 3, 2001.
September 11 – September 30, 2001
Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

11

12

13

14

15

hours

hours

hours

hours

hours

16

17

18

19

20

21

22

hours

hours

hours

hours

hours

hours

hours

23

24

25

26

27

28

29

hours

hours

hours

hours

hours

hours

hours

30
hours

October 1 – October 3, 2001
Sunday

Monday

Tuesday

Wednesday

Thursday

1

2

3

hours

hours

hours

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Application Page 5 of 15

Friday

Saturday

WTC Health Program Application for Enrollment—Pentagon/Shanksville Responder

Workers’ Compensation Information
Have you filed a claim for workers’ compensation or for another work-related injury or illness benefit for any injuries or
illnesses arising out of your exposure or your rescue, recovery, debris cleanup, or related support services activities in the
aftermath of the September 11, 2001?  Yes  No
If yes, in what state was your claim filed and when?
Please note: Workers’ Compensation information is not used to determine your eligibility for the WTC Health Program. It
is needed for the administrative purposes of coordinating payments if you are enrolled. The Program is required by law to
coordinate payment with your workers’ compensation carrier or recoup money from a workers’ compensation settlement,
if applicable. More information on this process is available at www.cdc.gov/wtc/handbook.html#coverage. You will also
be asked periodically to update this information as a member.

Required Supporting Documentation
You must submit copies of supporting documentation with your application. Your supporting documentation must
show that you satisfy the eligibility requirements for a Pentagon/Shanksville Responder by showing the address and/or
street name of where you worked (location), the type of work you performed (activity) at each location, the time period you
worked at each location, and how many hours per day you worked at each location.
Documentation may include, but is not limited to:
•

Letter from your employer or union stating your activities, location, days, and hours performing Pentagon
and/or Shanksville, PA, site activities on or after September 11, 2001.

•

Police memo book (including a copy of the cover page) that shows the days, times, and hours worked at the
Pentagon and/or Shanksville, Pennsylvania, site.

•

Timesheet or overtime report that shows the day, hours, and street names of where you worked.

•

Awards or letters that commend your 9/11 activities if it includes dates and locations of work and duties
performed.

•

Letter from the Workers’ Compensation Board for your 9/11-related work if it includes dates and locations of
work and duties performed.

You may need to submit multiple documents to show your name, activity, location, time period, and how many hours per
day you worked at each location on or after September 11, 2001. You must submit a document to show your official name
change if the last name on your application does not match the last name supplied in your supporting documentation.
If you cannot find official supporting documentation or it doesn’t provide all necessary details, you can do one of the
following:
•

Submit a signed, written statement by an employer, co-worker, or other individual that indicates the type of work
you performed, location(s) where you worked (with address or street name), time period you worked at each
location, and hours worked per day, or

•

Provide a signed statement written by yourself attesting, under penalty of perjury, to the details of your
9/11-related work, location, and time period Your personal letter must also include details about what you did to try
to get copies of your documentation and why you are not able to provide any.

Please note: Submitting an application without supporting documentation will delay your enrollment decision. If
you have questions, please call 1-888-982-4748 or visit www.cdc.gov/wtc/documentation.html.

Do not write in this space

Application Page 6 of 15

WTC Health Program Application for Enrollment—Pentagon/Shanksville Responder

Additional Information
Government Identification Number
We ask that you provide one (1) of the following:
Social Security Number
State ID/Driver’s License Number and Issuing State

Passport Number and Issuing Country
Other (include type of ID)
 I prefer not to provide a Government Identification Number (Selecting this option will not affect your enrollment decision)

Organization Affiliations
Please list any professional organizations, associations, or unions you were a member of on 9/11 or the time after. For a
union, provide the local number, if any. Providing this information is voluntary. This information may help determine what
types of supplemental documentation might be available to support your application.

Health Insurance
The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act), as amended, requires that all members
of the WTC Health Program have primary health insurance, including pharmacy and medical coverage, unless a limited
exception applies.
The WTC Health Program does not replace your primary health insurance. Please provide information on your primary
health insurance. You will be required to present your insurance card after enrollment in the Program. Although your
health insurance status will not affect your enrollment in the WTC Health Program, if you do not obtain primary health
insurance, it will impact the Program’s ability to pay for your monitoring and treatment.
Do you have primary health insurance? c Yes c No
If yes, is the insurance private or public?
c Private (e.g., through employer)

c Public (e.g., Medicare)

c Both (e.g., Medicare w/ private supplement)

Name of insurance plan/program name
Are you the primary policyholder?

c Yes c No

If you are not the primary policy holder, please provide the policyholder’s name
Member ID number

Group number

Coverage start date

Does your insurance include pharmacy benefits? c Yes c No

Note: If you do not have insurance, WTC Health Program benefits counselors or case managers can help you find and
apply for health insurance should you be enrolled.

Communications
How did you hear about the WTC Health Program (check all that apply)?
 TV/Radio/Print Ad

 Online

 Social Media

 WTC Health Registry  Law Firm

 VCF

 Work

 Labor Union

 Outreach Partner

 Other
Do not write in this space

Application Page 7 of 15

 Friend

WTC Health Program Application for Enrollment—Pentagon/Shanksville Responder

Declaration and Signature
Read the declaration below carefully, then initial and sign in the spaces provided.
By my initials and signature, I attest that:
Initials

I hereby apply to the WTC Health Program and give permission for my personal information to be used by
appropriate Federal Government agencies and Federal Government contractors to determine if I am eligible
for the WTC Health Program. This information is also used to ensure that, if enrolled, my Program benefits
and services are provided properly and that payments for Program services are processed correctly.

Initials

I have answered the questions in this application form truthfully and believe I meet the eligibility criteria for a
Pentagon/Shanksville Responder in the WTC Health Program.

Initials

I acknowledge that I have read the information in the Program Notices (attached) that includes important
information about Program benefits, services, regulations, and privacy.

Initials

Initials

I understand that any person who knowingly and willfully makes any false statement, misrepresentation,
concealment of fact, or any other act of fraud to gain enrollment or care in the WTC Health Program to
which that person is not entitled is subject to civil and/or administrative remedies as well as felony criminal
prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both
pursuant to 18 U.S.C. § 1001.
I understand that I am required to obtain primary health insurance for both pharmacy and medical coverage
and disclose my primary health insurance information to the Program before beginning treatment or follow-up
monitoring

PRINT NAME

SIGNATURE (Electronic signatures are not accepted.) DATE

Your application and supporting documentation may be faxed to 1-877-646-5308 or mailed to:
U.S. Postal Mail:
WTC Health Program
P.O. Box 7000
Rensselaer, NY 12144

Shipping Service or Certified Mail:
WTC Health Program
327 Columbia Turnpike
Rensselaer, NY 12144

Please note: Applications cannot be submitted by email. Save a copy of your completed application for your records. It is
also recommended that you bring the copy of your application to your first appointment.
If you need assistance with submitting your application or have any other Program-related questions, please call the WTC
Health Program at 1-888-982-4748. Program Notices referenced above are also available at www.cdc.gov/wtc.
What happens next?
After submitting your application, the WTC Health Program will:
•
•
•

Mail you a letter confirming receipt of your application within 30 days of receipt of your application.
Contact you by phone or mail if additional information or documentation is needed.
Review your application details and determine your eligibility based on the information provided.

Once all necessary information is received and reviewed, the Program will make a decision about your eligibility and
notify you by mail. If you are enrolled, your decision letter will include information on the Clinical Centers of Excellence or
Nationwide Provider Network available to you.
If you do not receive a letter confirming receipt of your application within 30 days of submission, please call
1-888-982-4748.
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Application Page 8 of 15

WTC Health Program Notices

Notices Regarding WTC Health Program Requirements
WTC Health Program Requirements, Services, and Benefits

Services provided under the World Trade Center (WTC) Health Program, a limited health care benefits program, include the
following:
Enrolled Screening-Eligible Survivors receive:


A one-time initial health evaluation


If the initial health evaluation does not result in a certified condition and a survivor wants an additional health
evaluation in the future for a new condition possibly WTC-related, they may pay out of pocket or use primary health
insurance to pay for an evaluation by a WTC Health Program doctor in the future.

Enrolled Responders and Certified-Eligible Survivors (Survivors with a certified WTC-related health condition) receive:


Annual monitoring exams,



Medical and mental health treatment for certified WTC-related health conditions, and



Benefits counseling services.

Cancer screening is available to all WTC Health Program members (except FDNY family members) who meet the age and risk
guidelines of the U.S. Preventive Services Task Force.
Services are provided through Clinical Centers of Excellence (CCEs) in the New York metropolitan area or through the
Nationwide Provider Network (NPN). The Administrator of the WTC Health Program, designated as the Director of the National
Institute for Occupational Safety and Health (NIOSH), determines eligibility for enrollment and certifies an enrolled member’s
condition for treatment.

WTC-Related Health Conditions

The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act), which established the WTC Health Program,
designated the original List of WTC-Related Health Conditions (the List) covered for treatment (sections 3312(a)(3) and 3322(b)
of the Public Health Service Act). Additional health conditions may be added to the List by the Administrator of the WTC Health
Program through rulemaking. More information on covered conditions is available
at www.cdc.gov/wtc/conditions.html.

Monitoring and Treatment

The WTC Health Program provides annual medical monitoring for enrolled Responders. Survivors receive annual medical
monitoring if certified with a WTC-related health condition(s), referred to as a Certified-Eligible Survivor. Medical monitoring
is intended to detect symptoms and illnesses that may be WTC-related, and include a physical exam, breathing tests, mental
health assessment, exposure assessment, routine blood and urine tests that do not include drug or HIV testing, and referral for
treatment if necessary. Eligible Responders and Certified-Eligible Survivors, including those eligible under prior programs, will
receive these monitoring benefits and treatment that is medically necessary for both certified WTC-related health conditions and
certain medically related conditions.
If a WTC Health Program doctor determines a member has a WTC-related health condition based on the initial health evaluation
or medical monitoring examination, the Administrator of the WTC Health Program must first certify the condition for coverage
and approve the treatment provided. Covered treatment is available for certified WTC-related health conditions and certain
health conditions medically associated with a certified WTC-related health condition. Treatment for a certified WTC-related
health condition must be provided by a WTC Health Program-affiliated provider.
These services and benefits are voluntary for members. Members may withdraw from participation in the WTC Health Program
at any time, without any financial or other consequences other than loss of Program services.

Pharmacy Benefits

Members are entitled to pharmacy benefits for certified WTC-related or medically associated conditions. The WTC Health
Program contracts with one or more pharmaceutical providers and has the discretion to change pharmaceutical provider(s) at
any time.

Appendix Page 9 of 15

WTC Health Program Notices

Payment for Services

The WTC Health Program will cover the cost of medically necessary care from Program providers for certified WTC-related
health conditions and coordinate payment with any other private or public healthcare plans (e.g., Medicare).
For Responders, the Program is the first payer for all monitoring and treatment, paying for all services received through the
Program unless the Responder has an established workers’ compensation case for the certified health condition(s). If there is
an established workers’ compensation case for the Responder’s certified WTC-related condition, a workers’ compensation fund
will be the first payor. The WTC Health Program is required to reduce or recoup payment for treatment of a WTC-related health
condition if such condition is covered by a workers’ compensation or similar work-related injury or illness plan. For Responders
who are being treated within the Program for work-related certified WTC-related health conditions and who do not receive
workers’ compensation for that condition, the WTC Health Program is the first payor.
For Survivors, the Program pays in full for the initial health evaluation and, if certified-eligible, annual monitoring exams. For
treatment of a certified WTC-related health condition, the Program is the secondary payer. This means that the Program will bill
the Survivor’s private health insurance first, then any public health insurance (e.g., Medicare or Medicaid). Once other health
insurance providers have paid, the Program pays any remaining amount. If a Survivor has a certified WTC-related health
condition that is work-related and has a workers’ compensation claim for the condition, the Program will pay initially and then
seek recoupment from either the workers’ compensation carrier or the settlement, where applicable.
The Program may share a member’s protected health information and/or personally identifiable information (e.g., medical
records) with these potential payers for reimbursement purposes. The WTC Health Program may also exchange protected
health information and/or personally identifiable information with the Centers for Medicare and Medicaid Services and WTC
Health Program contractors for payment purposes.
Please note: the WTC Health Program is not a substitute for personal health insurance. The WTC Health Program is a limited
health care benefits program and only provides treatment for certified WTC-related health conditions. The WTC Health Program
does not provide the full breadth of general health care and is not a substitute for visits to the member’s own primary care
physician or other healthcare provider.
Participation in the WTC Health Program does not prevent members from seeing their personal physician or obtaining any
medical evaluation or treatment from any other provider at their own expense. Responders and Survivors are responsible for
obtaining necessary follow-up evaluations and treatment at their own expense for any health conditions that are not determined
to be WTC-related conditions or are not pre-authorized by the member’s WTC Health Program provider and the WTC Health
Program.

Patient Protection and Affordable Care Act

The Affordable Care Act (ACA), sometimes known as Obamacare, was effective on January 1, 2014. The ACA requires
everyone to maintain minimum essential health care coverage, absent an approved exemption. The Zadroga Act requires that
Program members meet the ACA requirements as of July 1, 2014.
The WTC Health Program may not pay for monitoring or treatment of any member, responder or survivor, unless the member
has current personal health insurance that meets the minimum essential coverage requirement or falls under a limited exception.
If you do not have insurance, WTC Health Program benefits counselors can help you find and apply for health insurance should
you be enrolled.
Please contact a specially trained ACA counselor (or navigator) for direct help to select and act on the option that is right for you:
1. Federal ACA counselors can be reached at 1-800-318-2596 (TTY: 1-855-889-4325) 24 hours a day, 7 days a week
(except holidays); or
2. New York State ACA counselors can be reached at 1-855-355-5777 (TTY: 1-800-662-1220) Monday-Friday (8 a.m.-8
p.m. and Saturday 9 a.m.-1 p.m.); or
3. Find local help/agent-broker help on demand at localhelp.healthcare.gov
You can also get information on the Federal ACA website at www.healthcare.gov and on the New York State ACA website at
nystateofhealth.ny.gov.

Applications

The WTC Health Program will evaluate applications on a first-come, first-served basis.

Terrorist Watch List

The Zadroga Act requires that the Administrator of the WTC Health Program determine whether a Program applicant is in
the Terrorist Screening Database (commonly known as the “terrorist watch list”) prior to enrollment. The Administrator of the
WTC Health Program will consult with the Department of Justice to determine whether an applicant is on the terrorist watch
list. Individuals determined to be on this list are not qualified for enrollment in the WTC Health Program. This also applies to
Responders and Survivors who were eligible for treatment and benefits under prior WTC programs. More information on the
terrorist watch list is available at www.fbi.gov/about/leadership-and-structure/national-security-branch/tsc.

Appendix Page 10 of 15

WTC Health Program Notices

Any disclosure of personally identifiable information to the Department of Justice will be limited to what is necessary to
determine terrorist watch list status. Personally identifiable information will be destroyed or returned to the WTC Health Program
once it is determined that the individual is not on the terrorist watch list.

Appeals Process

Members are entitled to appeal decisions made by the Administrator of the WTC Health Program (the Administrator) regarding
enrollment, certification of health conditions, and provision of treatment and benefits. An individual or their designated
representative may appeal the decision in writing within 120 days of the date on the enrollment decision letter. The appeal must
state the reason(s) why the member believes the Administrator’s decision is incorrect, among other requirements. Appeals of
Program policy, regulations, or law are invalid appeals. Please note: Members are not entitled to appeal a determination by a
Program provider that a condition does not satisfy certification criteria and a certification request will not be submitted.
Upon receiving a valid appeal request, the Administrator will designate a Federal Official who is independent of the Program
to review the case and make a recommendation. The Federal Official may consider new information that was not previously
submitted with the application and considered by the WTC Health Program. The Administrator will review the Federal Official’s
recommendation and make a final decision on the appeal.
The Administrator may reopen and reconsider a denial at any time. An appeal related to an enrollment denial based on
information from the terrorist watch list will be delegated to the appropriate Federal agency.

September 11th Victim Compensation Fund

The September 11th Victim Compensation Fund (VCF) provides financial compensation to individuals (or a personal
representative of a deceased individual) who were present at the World Trade Center or in the VCF’s NYC Exposure Zone
(www.vcf.gov/nyc-map-exposure-zone); the Pentagon crash site; or the Shanksville, Pennsylvania, crash site, at some point
between September 11, 2001, and May 30, 2002, and who have been diagnosed with a 9/11-related physical illness. The VCF
does not compensate for mental health conditions and does not distinguish between responders and survivors.
The VCF is administered by the Department of Justice and is a separate federal program under the Zadroga Act. Enrollment in
the WTC Health Program does not automatically register you with the VCF. Please visit the VCF website for more information at
www.vcf.gov or call 1-855-885-1555.
Responders or Survivors who have applied for benefits from the WTC Health Program may also apply for benefits from the
VCF. The VCF requires applicants to sign an authorization form permitting the Department of Justice to share protected
health information and/or personally identifiable information (including medical records) with other entities such as the WTC
Health Program. Therefore, the WTC Health Program may disclose protected health information and/or personally identifiable
information to the VCF if a VCF applicant is also a member of the WTC Health Program.
The VCF may also request information from the WTC Health Program related to a member’s certified WTC-related health
condition and treatment, about any WTC Health Program certification or requested certification of the WTC Health Program
member’s WTC-related health condition, and the member’s eligibility for treatment.
Information regarding costs and payment for treatment of a WTC Health Program member may also be shared with VCF. VCF
compensation awards may be reduced by the cost of the treatment the individual receives or is entitled to receive, including
through the WTC Health Program.

Clinical Centers of Excellence

The WTC Health Program contracts with Clinical Centers of Excellence (CCEs) to provide eligible members with initial health
evaluations, monitoring, treatment, and other services. In compliance with the Zadroga Act, the CCEs also collect and report
data, including data about medical claims, to the WTC Health Program Data Centers.

Data Centers

In accordance with the Zadroga Act, the WTC Health Program contracts with Data Centers to do the following:
1. Receive, analyze, and report data collected from the CCEs and the Nationwide Provider Network (NPN) to the WTC
Health Program;
2. Develop initial health evaluation, monitoring, and treatment protocols with respect to WTC-related health conditions;
3. Coordinate the outreach activities of the CCEs;
4. Establish criteria for credentialing of medical providers participating in the NPN (see below);
5. Coordinate and administer the activities of the WTC Health Program Steering Committees; and
6. Meet periodically with the CCEs to obtain input on the analysis and reporting of data and on development of monitoring,
initial health evaluation, and treatment protocols.

Appendix Page 11 of 15

WTC Health Program Notices

Nationwide Provider Network

The WTC Health Program contracts with a Nationwide Provider Network (NPN) to provide initial health evaluation, monitoring,
treatment, and benefits to eligible members who reside in areas outside of the New York metropolitan area. These individuals
may choose to receive WTC Health Program benefits from a CCE. NPN providers must meet qualifications established by Data
Centers. Like the CCEs, the NPN collects and reports data, including data about claims, to the Data Centers.

Designated Representatives

Responders and Survivors may designate a person to act on their behalf and represent their administrative interests in the
WTC Health Program. A designated representative may provide and obtain personal information regarding your application to
the WTC Health Program, your benefits, and your membership in the Program. A designated representative can also 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 any individual (not a group or firm) if their service as a designated representative does not
violate any applicable provision of law. Members can only have one (1) designated representative at a given time. A parent or a
legal guardian may act on behalf of a minor seeking monitoring or treatment services under the WTC Health Program.
By designating a representative, you are authorizing the WTC Health Program to disclose your personal information to the
individual and authorizing that individual to 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. However, this person
may not make medical care (e.g., treatment) decisions on your behalf.
Please note: Any requirement of the WTC Health Program to notify you in writing is fully satisfied if sent to the designated
representative. The WTC Health Program does not generally accept Powers of Attorney for administrative matters. This includes
signing and/or submitting an application on an individual’s behalf, signing Designated Representative forms on an individual’s
behalf, and otherwise interacting with the WTC Health Program on an individual’s behalf.
To designate a representative, a member must fill out and submit a Designated Representative form and a Designated
Representative HIPAA Authorization form to the Program. More information and the forms are available at
www.cdc.gov/wtc/designated_representative.html or by calling 1-888-982-4748.

Disruptive and Abusive Behavior

The WTC Health Program believes that all individuals have a right to a safe working environment. Disruptive or abusive behavior
by a WTC Health Program applicant or member at or directed towards a facility or personnel affiliated with the Program (e.g., a
CCE, the NPN, providers, or staff) will not be tolerated.
These types of behavior include, but are not limited to, acts of violence or threats against staff or other patients (including verbal
or physical abuse), rude or vulgar language (including cursing or shouting), throwing and striking objects, harassing or stalking,
concealing or using a weapon, and engaging in criminal behavior.
Depending on the particular circumstances, members who engage in such behaviors may have their care suspended by their
CCE or NPN provider, be required to sign a behavioral agreement outlining what will be expected of them in order to receive
care from their provider, be required to transfer to another CCE or NPN provider, or be subject to other appropriate actions,
including involvement of law enforcement authorities as necessary.
The Program strives to provide high-quality, compassionate care for members’ WTC-related health needs. Disruptive or abusive
behavior, however, may impact the Program’s ability to provide benefits in a timely manner.

Penalties

If a Responder or Survivor knowingly and willfully provides false information to the WTC Health Program, including on the
application for enrollment, they may be subject to a fine and/or imprisonment of not more than five years.
For more information about the WTC Health Program, please refer to the authorizing statute and federal regulations (see Title
XXXIII of the Public Health Service Act, 42 U.S.C. §§ 300mm - 300mm-61; 42 C.F.R. Part 88). Links to the statute and federal
regulations are available at www.cdc.gov/wtc/laws.html.
Updated December 2021

Appendix Page 12 of 15

WTC Health Program Notices

Privacy Act Statement and Additional Permitted Disclosures of Personally Identifiable Information and
Records

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. § 552a), you are hereby notified that the World Trade Center
(WTC) Health Program is administered by the Department of Health and Human Services (HHS), which receives and maintains
personal information on applicants under the statutory authority found at 42 U.S.C. §§ 300mm - 300mm-61. The information
received is required to determine eligibility and qualification for the WTC Health Program and for any subsequent initial health
evaluations, monitoring and treatment, or other benefit under the WTC Health Program. Failure to provide this information may
prevent or delay the process of an application or determination of eligibility. 
In addition to those WTC Health Program uses outlined above, and as allowed by the Privacy Act, information and records
on responders and survivors submitted to or developed by the WTC Health Program may be disclosed to specific individuals/
entities for certain routine uses, including the following:
1. Department of Justice (DOJ), in the event of litigation where HHS, any component of HHS, any employee of HHS, or
the United States is involved. Such disclosure may be made to DOJ to enable that Department to present an effective
defense, provided that such disclosure is compatible with the purpose for which the records were collected;
2. DOJ and its contractors, to provide terrorist screening support in accordance with the WTC Health Program’s statutory
obligation to determine whether an individual is on the “terrorist watch list” as required by 42 U.S.C. §§ 300mm-21 and
300mm-31 and is qualified to be enrolled in the WTC Health Program;
3. DOJ, in order to aid DOJ in the implementation of Title II of the Zadroga Act regarding the September 11th Victim
Compensation Fund, to provide information pertaining to an individual’s enrollment in the WTC Health Program, the
WTC Program Administrator’s decision regarding whether an individual’s medical condition is certified as a WTC-related
health condition or a health condition medically associated with a WTC-related health condition, and the WTC Program
Administrator’s decisions regarding the authorization of treatment and payment for health evaluations, monitoring, and
treatment;
4. Contractors performing or working on a contract for HHS who require access to information to perform duties or
activities for HHS (in accordance with the law and the contract);
5. Federal agencies or an entity under governmental jurisdiction that administer or has the authority to investigate potential
fraud, waste, or abuse in a health benefits program administered using Federal funds. Such disclosure of information
must be found reasonably necessary by the WTC Health Program to prevent, deter, discover, detect, investigate,
examine, prosecute, sue with respect to, defend against, correct, remedy, or combat fraud, waste, or abuse in the WTC
Health Program;
6. State and local health departments may receive information about certain diseases or exposures, where the State has
a legally constituted reporting program for communicable diseases and which provides for the confidentiality of the
information. This may include official State registries;
7. Members of Congress or Congressional staff members who have submitted a verified request involving an individual
who is entitled to the information and has requested assistance from the Member of Congress or Congressional staff
member;
8. To a member’s personal representative where the member has authorized such individual to represent him or her in
regard to the WTC Health Program. The member may appoint one individual to represent his or her interests under the
WTC Program and the appointment must be in writing. If a member is a minor, a parent or guardian may act on his or
her behalf;
9. National Institute for Occupational Safety and Health (NIOSH) collaborating researchers (e.g., NIOSH contractors,
grantees, cooperative agreement holders, Federal or State scientists) to accomplish the research purpose for which the
records are collected;
10. Social Security Administration, in connection with public health activities, for sources of locating information to
accomplish the research or program purposes for which the records were collected; and
11. Applicable entities for the purpose of reducing or recouping WTC Health Program payments for treatments based on
other payments made to individuals under a workers’ compensation law or plan of the United States, a State, or locality,
or other work-related injury or illness benefit plan of the employer of such worker or public or private health plan as
required under 42 U.S.C. § 300mm-41.
The current System of Records Notice (SORN) was published in the Federal Register on June 14, 2011, 76 Fed. Reg. 34706,
and includes the above-referenced disclosures as required by the Privacy Act. You can access the current SORN and any future
updates to the SORN at the following website address: https://www.cdc.gov/SORNnotice/09-20-0147.htm. Any amendments
to the current SORN may include additional disclosures of personal information.

Appendix Page 13 of 15

WTC Health Program Notices

Notice of Privacy Practices Regarding Your Personal Health Information

This notice describes how medical information about you may be used and disclosed and how you can get access to this
information. Please review it carefully.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the World Trade Center (WTC) Health Program
to maintain the privacy and security of your personal health information and to provide you with notice of its legal duties and
privacy practices with respect to how your personal health information is held, used, and disclosed by the WTC Health Program.

How Do We Use and Share Your Personal Health Information?

The WTC Health Program must use and share your personal health information to provide information:


To you, someone you name to receive your personal health information, or someone who has the legal right to act for
you (the WTC Health Program will make sure that the person has the proper authority before taking any action);



To the Secretary of the Department of Health and Human Services (HHS), if necessary, to make sure your privacy is
protected and that the HIPAA requirements are being followed; and



Where required by law.

How Else Do We Use and Share Your Personal Health Information?

The WTC Health Program may use and share your personal health information to provide you with treatment, to pay for your
health care, and to operate the WTC Health Program. For example, the WTC Health Program may use or share your personal
health information in the following ways:


The WTC Health Program will collect and use your personal health information to decide if you meet the necessary
requirements for coverage of your health condition(s) under the WTC Health Program. Conditions which meet these
requirements are then “certified” by the WTC Health Program.



The WTC Health Program will collect and use your personal health information to determine your diagnosis and any
medically necessary treatment for your “certified” health conditions.



The WTC Health Program will disclose your personal health information to the Centers for Medicare and Medicaid
Services (CMS) Office of Financial Management to pay providers for eligible health care services you received.



The WTC Health Program will review and use your personal health information to make sure you are receiving quality
healthcare.

Under limited circumstances, the WTC Health Program may use or share your personal health information for the following
purposes:


To other federal and state agencies, where allowed by federal law, that need WTC Health Program health data for their
program operations;



For public health activities conducted by public health authorities (such as reporting disease outbreaks);



For health care oversight activities (such as fraud and abuse investigations);



For judicial and administrative proceedings (such as in response to a court order);



For law enforcement purposes;



To avoid a serious and imminent threat to health or safety;



For purposes of reporting information to a government authority about victims of abuse, neglect, or domestic violence;



To report information about deceased individuals to a coroner, medical examiner, or funeral director;



To organ procurement organizations for organ or tissue donation and transplantation purposes;



For research purposes under certain conditions;



For workers’ compensation purposes; or



To contact you about new or changed coverage under the WTC Health Program.

What Are Your Rights When It Comes To Your Personal Health Information?

When it comes to your personal health information, you have certain rights. By law, you have the right to:


Receive a paper copy of this privacy notice. You can ask for a paper copy of this notice even if you have already
received an electronic copy (for example, by email). We will provide you with a paper copy promptly upon request.



Receive a list that shows with whom we have shared your personal health information. You can ask for a list
(accounting) of the times we have shared your personal health information for six years prior to the date you ask. The
list shows whom we shared it with, when, and why. The list does not include information about treatment, payment,
health care operations, and certain other disclosures (such as any you asked us to make). We will provide one free
accounting a year but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Appendix Page 14 of 15

WTC Health Program Notices



Receive a copy your personal health information. You can ask to see or get a copy of your health and claims
records and other health information that we have about you. You can contact us by using the information included in
the last page of this notice. We will provide a copy or a summary of your health and claims records, usually within 30
days of your request. We may charge a reasonable, cost-based fee to send your health and claims records.



Ask us to change (“amend”) your personal health information. You can request to change your records if you
believe that your personal health information is wrong or that information is missing. Please note that we may deny
your request to change your personal health information if we believe the information in your records is accurate
and complete. If your request is denied, we will provide you with a written explanation of the denial within 60 days of
the date we received your request. You may have a statement added to your personal health records to reflect your
disagreement.



Request confidential communications. You may request that we communicate your personal health information in a
private (“confidential”) way. You may ask that we contact you in a specific way (for example, home or office phone) or to
send mail to a different address.



Ask us to limit how we use and share your personal health information. You can ask us not to use or share certain
health information. We are not required to agree to the limits you request, except under certain circumstances.



Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal
guardian, that person can exercise your rights and make choices about your personal health information. We will make
sure the person has this authority and can act for you before we take any action.



Receive breach notification. You can expect to be informed of and receive notification if a breach occurs that may
have compromised the privacy or security of your information.

When Do We Require Your Written Permission?

By law, the WTC Health Program must have your written permission (authorization) to use or share your personal health
information for any purpose that is not set out in this notice, including certain uses or disclosures of psychotherapy notes. In
addition, the WTC Health Program will not sell or market your personal health information without your written permission.
You may take back (revoke) your written permission anytime, except in cases where the WTC Health Program has already acted
on your permission. If you take back your written permission, please provide that to the WTC Health Program in writing.
The WTC Health Program is prohibited from using or sharing your personal genetic health information (i.e., your genetic tests,
the genetic tests of your family members, and your family medical history) to determine your eligibility and enrollment into the
WTC Health Program (i.e., underwriting).

What Are the Responsibilities of the WTC Health Program?

The WTC Health Program is required by law to abide by the terms of this privacy notice. The WTC Health Program has the right
to change this privacy notice and the changes will apply to all the information that we have about you. If we make any significant
changes to this notice, a copy of the revised notice will be made electronically available on the WTC Health Program website
and you will receive the new notice by mail or email within 60 days. You may also request to receive a copy of the notice at any
time.

How Can You Contact the WTC Health Program?

You can call 1-888-982-4748 to get further information about matters covered by this notice. Ask to speak to a customer service
representative about the WTC Health Program’s HIPAA privacy notice. To view an electronic copy of the WTC Health Program’s
HIPAA privacy notice, you can visit the WTC Health Program’s website at www.cdc.gov/wtc/privacy.html.

How Can You File a Complaint?

If you believe that your privacy rights have been violated, you may file a complaint with the WTC Health Program by calling
1-888-982-4748 or by sending a letter to P.O. Box 7000 Rensselaer, NY 12144 ATTN: WTC Health Program, HIPAA Complaint.
Filing a complaint will not affect your coverage under the Program. You may also file a complaint with the HHS Office for Civil
Rights by sending a letter to 200 Independence Avenue, SW, Washington, DC 20201, calling 1-877-696-6775, or visiting
www.hhs.gov/ocr/privacy/hipaa/complaints/. TTY users should call 1-800-537-7697.
This Notice of Privacy Practices for the WTC Health Program is effective September 23, 2020.

Appendix Page 15 of 15