OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

World Trade Center Health Program Enrollment, Appeals & Reimbursement

ICR 202201-0920-002 · OMB 0920-0891 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-0891 Designated Representative Revocation Form Form and Instruction New Missing upstream
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction New Repair queued
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction New Repair queued
Form 0920-0891 Member Satisfaction Survey Form and Instruction New Repair queued
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Modified Repair queued
Reimbursement Denial Letter and Appeal Notification - Providers Form and Instruction Removed Repair queued
HIPAA Authorization to Release Information Form and Instruction Modified Repair queued
Decertification Letter and Appeal Notification for a Health Condition Form and Instruction Removed Repair queued
Disenrollment and Appeal Process for Responders Form and Instruction Removed Repair queued
Designated Representative Form and Instruction Modified Repair queued
Request for Certification of Health Condition (WTC-3) Form and Instruction Removed Repair queued
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 Removed Missing upstream
Responder Denial Ltter and Appeal Notification - Treatment Form and Instruction Removed Missing upstream
Responder Denial and Appeal - Health Conditions Form and Instruction Removed Repair queued
Responder Denial and Appeal - Eligibility Form and Instruction Removed Repair queued
Survivor Eligibility Application Form and Instruction Modified Repair queued
Pentagon / Shanksville Responder Form and Instruction Modified Repair queued
General Responder Eligibility Application Form and Instruction Modified Repair queued
FDNY Responder Eligibility Application Form and Instruction Modified Repair queued
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Missing upstream
App X Survivor 90 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App W 60 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App V 30 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App U Initial Request for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App ZZ Disenrollment Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Available
App QQ Certification Denial Letter and Appeal.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App AAA Decert Letter Template Admin Error.docx Supplementary Document Uploaded 2022-01-06 Missing upstream
App DDD Summary of Forms and Changes.docx Supplementary Document Uploaded 2022-01-06 Repair queued
SSB-Update-91321.docx Supporting Statement B Uploaded 2022-01-06 Missing upstream
SSA-Update-091321.docx Supporting Statement A Uploaded 2022-01-06 Repair queued
60d FRN published.pdf Supplementary Document Uploaded 2022-01-06 Missing upstream
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 Repair queued
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
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 Missing upstream
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 Repair queued
App Y-1. General PA3 Form.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document Uploaded 2018-09-20 Repair queued
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App SS Summary of Forms and Changes_100918.docx Supplementary Document Uploaded 2018-10-09 Missing upstream
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 Repair queued
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 Repair queued
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 Repair queued
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 Missing upstream
App W Prior Authorization Form_Dental.pdf Supplementary Document Uploaded 2018-09-20 Missing upstream
App V Prior Authorization Form_Standard.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
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 Repair queued
App Q 180 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App P 90 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
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 Missing upstream
App M Initial Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
Appendix A Legislation.docx Supplementary Document Uploaded 2014-12-18 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
251030 Designated Representative Revocation Form Form and Instruction New
251023 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction New
251018 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction New
251017 Member Satisfaction Survey Form and Instruction New
233098 Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Modified
233096 Reimbursement Denial Letter and Appeal Notification - Providers Form and Instruction Removed
233095 HIPAA Authorization to Release Information Form and Instruction Modified
233094 Decertification Letter and Appeal Notification for a Health Condition Form and Instruction Removed
233092 Disenrollment and Appeal Process for Responders Form and Instruction Removed
218099 Pharmacy - Outpatient Prescription Pharmaceuticals Other-Dummy Form Representing an Electronic Data Transfer Removed
218098 Designated Representative Form and Instruction Modified
218097 Request for Certification of Health Condition (WTC-3) Form and Instruction Removed
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 Removed
214336 Responder Denial Ltter and Appeal Notification - Treatment Form and Instruction Removed
214335 Responder Denial and Appeal - Health Conditions Form and Instruction Removed
214327 Responder Denial and Appeal - Eligibility Form and Instruction Removed
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 202201-0920-002
Received in OIRA 201703-0920-004
HHS/CDC 0920-0891
World Trade Center Health Program Enrollment, Appeals & Reimbursement
Reinstatement with change of a previously approved collection   No
Regular 01/06/2022
  Requested Previously Approved
36 Months From Approved
28,977 0
12,882 0
146,417 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
  86 FR 22967 04/30/2021
86 FR 70841 12/13/2021
Yes
12
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
Decertification Letter and Appeal Notification for a Health Condition n/a Decertification Letter and Appeal Notification - Health Condition
Designated Representative n/a Designated Representative Form
Designated Representative Revocation Form 0920-0891 Designated Representative Revocation Form
Disenrollment and Appeal Process for Responders n/a Disenrollment Letter and Appeal Notification
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]
HIPAA Authorization to Release Information n/a HIPAA Authorization Form to Release Information
Member Satisfaction Survey 0920-0891 Member Satisfaction Survey
Pentagon / Shanksville Responder n/a Pentagon / Shanksville Responder Eligibility Application
Petition for the Addition of a Health Condition (previously approved under 0920-0929) n/a Petition for the addition of health conditions
Pharmacy - Outpatient Prescription Pharmaceuticals
Reimbursement Denial Letter and Appeal Notification - Providers n/a Reimbursement Denial Letter and Appeal Notification - Providers
Request for Certification of Health Condition (WTC-3) n/a Request for Certification of a WTC Related Health Condition
Responder Denial Ltter and Appeal Notification - Treatment n/a Denial Letter and Appeal Notification for Treatment Authorization
Responder Denial and Appeal - Eligibility n/a Enrollment Denial Letter and Appeal Notification
Responder Denial and Appeal - Health Conditions n/a Denial Letter and Appeal Notification - Health Condition Certification
Responder Medical Travel Refund Request n/a Medical Travel Refund Request
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]
WTC Health Program General HIPAA Authorization to Third Parties 0920-0891 WTC Health Program HIPAA Authorization - Third Parties
WTC Health Program HIPAA Authorization for Deceased Individuals 0920-0891 WTC Health Program HIPAA Authorization - Deceased Individuals
  Total Request 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 28,977 0 0 -38,017 0 66,994
Annual Time Burden (Hours) 12,882 0 0 -1,181 0 14,063
Annual Cost Burden (Dollars) 146,417 0 0 -946,295 0 1,092,712
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
Reinstatement is submitted to remove/add forms to 0920-0891 ICR package resulting in net decrease of 1,181 Burden Hours.
$323,763
No
    Yes
    Yes
No
No
No
No
Jeffrey Zirger 404 639-7118 [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.
01/06/2022