OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

World Trade Center Health Program Enrollment, Appeals & Reimbursement

ICR 201703-0920-004 · OMB 0920-0891 · Active

Forms and Documents
DocumentTypeStatusAvailability
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction New Available
Reimbursement Denial Letter and Appeal Notification - Providers Form and Instruction New Repair queued
HIPAA Authorization to Release Information Form and Instruction New Repair queued
Decertification Letter and Appeal Notification for a Health Condition Form and Instruction New Available
Disenrollment and Appeal Process for Responders Form and Instruction New Repair queued
Designated Representative Form and Instruction Modified Repair queued
Request for Certification of Health Condition (WTC-3) Form and Instruction Modified Available
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Modified Repair queued
Responder Medical Travel Refund Request Form and Instruction Modified Repair queued
Responder Denial Ltter and Appeal Notification - Treatment Form and Instruction Modified Available
Responder Denial and Appeal - Health Conditions Form and Instruction Modified Available
Responder Denial and Appeal - Eligibility Form and Instruction Modified Repair queued
Survivor Eligibility Application Form and Instruction Modified Available
Pentagon / Shanksville Responder Form and Instruction Modified Repair queued
General Responder Eligibility Application Form and Instruction Modified Available
FDNY Responder Eligibility Application Form and Instruction Modified Repair queued
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-10. NF PA3 Nucala.pdf Supplementary Document Uploaded 2018-10-09 Available
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document Uploaded 2018-10-09 Available
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document Uploaded 2018-10-09 Available
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-2. PA3 Renewal Form.pdf Supplementary Document Uploaded 2018-10-09 Available
App Y-1. General PA3 Form.pdf Supplementary Document Uploaded 2018-10-09 Available
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document Uploaded 2018-09-20 Available
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document Uploaded 2018-09-20 Available
App SS Summary of Forms and Changes_100918.docx Supplementary Document Uploaded 2018-10-09 Repair queued
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App PP Disenrollment and Decert Template.docx Supplementary Document Uploaded 2018-09-20 Available
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App JJ - Translated 180 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App II - Translated 90 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App HH - Translated 60 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Available
App GG - Translated 30 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App FF - Translated Initial Request for Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App EE IRB Determination.pdf Supplementary Document Uploaded 2018-09-20 Available
App DD-1 60-day FRN 05112018.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App X Prior Authorization Form_Transplant.pdf Supplementary Document Uploaded 2018-09-20 Available
App W Prior Authorization Form_Dental.pdf Supplementary Document Uploaded 2018-09-20 Available
App V Prior Authorization Form_Standard.pdf Supplementary Document Uploaded 2018-09-20 Available
App U WTC6 Medication Request.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App T WTC_5 Code or Procedure Request.pdf Supplementary Document Uploaded 2018-09-20 Available
App Q 180 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App P 90 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Available
App O 60 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App N 30 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Available
App M Initial Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Available
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document Uploaded 2018-09-20 Available
Appendix A Legislation.docx Supplementary Document Uploaded 2014-12-18 Available
SSB_10092018.docx Supporting Statement B Uploaded 2018-10-09 Available
SSA_10092018.docx Supporting Statement A Uploaded 2018-10-09 Available
IC Document Collections
IC IDCollectionTypeStatusForm
233098 Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction New
233096 Reimbursement Denial Letter and Appeal Notification - Providers Form and Instruction New
233095 HIPAA Authorization to Release Information Form and Instruction New
233094 Decertification Letter and Appeal Notification for a Health Condition Form and Instruction New
233092 Disenrollment and Appeal Process for Responders Form and Instruction New
218099 Pharmacy - Outpatient Prescription Pharmaceuticals Other-Dummy Form Representing an Electronic Data Transfer Modified
218098 Designated Representative Form and Instruction Modified
218097 Request for Certification of Health Condition (WTC-3) Form and Instruction Modified
218096 Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Modified
214337 Responder Medical Travel Refund Request Form and Instruction Modified
214336 Responder Denial Ltter and Appeal Notification - Treatment Form and Instruction Modified
214335 Responder Denial and Appeal - Health Conditions Form and Instruction Modified
214327 Responder Denial and Appeal - Eligibility Form and Instruction Modified
214326 Survivor Eligibility Application Form and Instruction Modified
214325 Pentagon / Shanksville Responder Form and Instruction Modified
214324 General Responder Eligibility Application Form and Instruction Modified
214323 FDNY Responder Eligibility Application Form and Instruction Modified
ICR Details
0920-0891 201703-0920-004
Active 201412-0920-012
HHS/CDC 19888
World Trade Center Health Program Enrollment, Appeals & Reimbursement
Revision of a currently approved collection   No
Regular
Approved without change 12/03/2018
Retrieve Notice of Action (NOA) 09/25/2018
  Inventory as of this Action Requested Previously Approved
12/31/2021 36 Months From Approved 11/30/2018
66,994 0 66,276
14,063 0 13,594
1,092,712 0 0
The WTC Health Program is a limited healthcare program established by the James Zadroga 9/11 Health and Compensation Act of 2010. The goal of the Program is to provide monitoring and treatment to responders of the 9/11 terrorist attacks at the World Trade Center, Pentagon, and Shanksville, PA, as well as survivors in the New York City Area. The data collected contained within this OMB package are intended solely for determining eligibility and treatment.
PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  
None
Not associated with rulemaking
  83 FR 22067 05/11/2018
83 FR 48428 09/25/2018
No
17
IC Title Form No. Form Name
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic n/a Clinic Selection Postcard
Request for Certification of Health Condition (WTC-3) n/a Request for Certification of a WTC Related Health Condition
Designated Representative n/a Designated Representative Form
Pharmacy - Outpatient Prescription Pharmaceuticals
Responder Denial and Appeal - Health Conditions n/a Denial Letter and Appeal Notification - Health Condition Certification
Responder Denial Ltter and Appeal Notification - Treatment n/a Denial Letter and Appeal Notification for Treatment Authorization
Responder Medical Travel Refund Request n/a Medical Travel Refund Request
FDNY Responder Eligibility Application n/a, n/a FDNY Responder Eligibility Application ,   Screen shots of Web interface for electronic reporting option
General Responder Eligibility Application n/a, n/a, n/a General Responder (other than FDNY) Eligibility Application [English] ,   General Responder (other than FDNY) Eligibility Application [Spanish] ,   General Responder (other than FDNY) Eligibility Application [Polish]
Pentagon / Shanksville Responder n/a Pentagon / Shanksville Responder Eligibility Application
Survivor Eligibility Application n/a, n/a, n/a, n/a Eligibility Application for Survivors [English] ,   Eligibility Application for Survivors [Spanish] ,   Eligibility Application for Survivors [Polish] ,   Eligibility Application for Survivors [Chinese]
Responder Denial and Appeal - Eligibility n/a Enrollment Denial Letter and Appeal Notification
Disenrollment and Appeal Process for Responders n/a Disenrollment Letter and Appeal Notification
HIPAA Authorization to Release Information n/a HIPAA Authorization Form to Release Information
Decertification Letter and Appeal Notification for a Health Condition n/a Decertification Letter and Appeal Notification - Health Condition
Reimbursement Denial Letter and Appeal Notification - Providers n/a Reimbursement Denial Letter and Appeal Notification - Providers
Petition for the Addition of a Health Condition (previously approved under 0920-0929) n/a Petition for the addition of health conditions
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 66,994 66,276 0 718 0 0
Annual Time Burden (Hours) 14,063 13,594 0 469 0 0
Annual Cost Burden (Dollars) 1,092,712 0 0 1,092,712 0 0
Yes
Changing Regulations
No
Some elements of information collection have been modified in response to changes in 42 CFR 88 which allows additional processes for WTC Health Program Members and applicants to appeal decisions.
$1,080,300
No
    Yes
    Yes
No
No
No
Uncollected
Renita Macaluso 770 488-6458 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/25/2018