OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

ICR 202402-0920-004 · OMB 0920-0891 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 0920-0891 Designated Representative Revocation Form Form and Instruction Unchanged Repair queued
Form 0920-0891 Designated Representative Revocation Form Form and Instruction Unchanged Repair queued
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Modified Available
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Modified Repair queued
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Modified Available
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Modified Repair queued
Form 0920-0891 Member Satisfaction Survey Form and Instruction Unchanged Repair queued
Form 0920-0891 Member Satisfaction Survey Form and Instruction Unchanged Repair queued
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Unchanged Available
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Unchanged Repair queued
HIPAA Authorization to Release Information Form and Instruction Unchanged Available
HIPAA Authorization to Release Information Form and Instruction Unchanged Repair queued
Designated Representative Form and Instruction Unchanged Available
Designated Representative Form and Instruction Unchanged Repair queued
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Unchanged Available
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Unchanged Repair queued
Survivor Eligibility Application Form and Instruction Unchanged Repair queued
Survivor Eligibility Application Form and Instruction Unchanged Repair queued
Pentagon / Shanksville Responder Form and Instruction Unchanged Available
Pentagon / Shanksville Responder Form and Instruction Unchanged Repair queued
General Responder Eligibility Application Form and Instruction Unchanged Repair queued
General Responder Eligibility Application Form and Instruction Unchanged Repair queued
FDNY Responder Eligibility Application Form and Instruction Unchanged Available
FDNY Responder Eligibility Application Form and Instruction Unchanged Repair queued
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-02-12 Available
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change Uploaded 2024-02-12 Repair queued
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Available
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App X Survivor 90 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Repair queued
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 Available
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 V 30 Day Suspend Letter.docx Supplementary Document Uploaded 2022-01-06 Missing upstream
App U Initial Request for Additional Information.docx Supplementary Document Uploaded 2022-01-06 Available
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 Available
App ZZ Disenrollment Letter.docx Supplementary Document Uploaded 2022-01-06 Missing upstream
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Available
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App QQ Certification Denial Letter and Appeal.docx Supplementary Document Uploaded 2022-01-06 Available
App QQ Certification Denial Letter and Appeal.docx Supplementary Document Uploaded 2022-01-06 Missing upstream
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document Uploaded 2022-01-06 Available
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 Available
App AAA Decert Letter Template Admin Error.docx Supplementary Document Uploaded 2022-01-06 Repair queued
App DDD Summary of Forms and Changes.docx Supplementary Document Uploaded 2022-01-06 Available
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 Available
SSB-Update-91321.docx Supporting Statement B Uploaded 2022-01-06 Repair queued
SSA-Update-091321.docx Supporting Statement A Uploaded 2022-01-06 Repair queued
SSA-Update-091321.docx Supporting Statement A Uploaded 2022-01-06 Repair queued
60d FRN published.pdf Supplementary Document Uploaded 2022-01-06 Available
60d FRN published.pdf Supplementary Document Uploaded 2022-01-06 Repair queued
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document Uploaded 2018-10-09 Available
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document Uploaded 2018-10-09 Missing upstream
App Y-10. NF PA3 Nucala.pdf Supplementary Document Uploaded 2018-10-09 Available
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 Available
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 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 Available
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document Uploaded 2018-10-09 Missing upstream
App Y-6. NF PA3 Antipsychotics.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-5. NF PA3 Antiemetics.pdf Supplementary Document Uploaded 2018-10-09 Repair queued
App Y-4. NF PA3 Antidepressants.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 Available
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document Uploaded 2018-10-09 Missing upstream
App Y-2. PA3 Renewal Form.pdf Supplementary Document Uploaded 2018-10-09 Available
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 Available
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 Available
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
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 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 Available
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 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 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 Available
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 II - Translated 90 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App HH - Translated 60 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Available
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 Available
App GG - Translated 30 Day Request for Information.docx Supplementary Document Uploaded 2018-09-20 Missing upstream
App FF - Translated Initial Request for Information.docx Supplementary Document Uploaded 2018-09-20 Available
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 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 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 Repair queued
App X Prior Authorization Form_Transplant.pdf Supplementary Document Uploaded 2018-09-20 Repair queued
App W Prior Authorization Form_Dental.pdf Supplementary Document Uploaded 2018-09-20 Available
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 Available
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 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 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 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 Repair queued
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 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 N 30 Day Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
App M Initial Letter Requesting Information.docx Supplementary Document Uploaded 2018-09-20 Repair queued
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 Available
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document Uploaded 2018-09-20 Repair queued
Appendix A Legislation.docx Supplementary Document Uploaded 2014-12-18 Repair queued
Appendix A Legislation.docx Supplementary Document Uploaded 2014-12-18 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
251030 Designated Representative Revocation Form Form and Instruction Unchanged
251030 Designated Representative Revocation Form Form and Instruction Unchanged
251023 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Modified
251023 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction Modified
251018 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Modified
251018 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction Modified
251017 Member Satisfaction Survey Form and Instruction Unchanged
251017 Member Satisfaction Survey Form and Instruction Unchanged
233098 Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Unchanged
233098 Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction Unchanged
233095 HIPAA Authorization to Release Information Form and Instruction Unchanged
233095 HIPAA Authorization to Release Information Form and Instruction Unchanged
218098 Designated Representative Form and Instruction Unchanged
218098 Designated Representative Form and Instruction Unchanged
218096 Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Unchanged
218096 Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form Unchanged
214326 Survivor Eligibility Application Form and Instruction Unchanged
214326 Survivor Eligibility Application Form and Instruction Unchanged
214325 Pentagon / Shanksville Responder Form and Instruction Unchanged
214325 Pentagon / Shanksville Responder Form and Instruction Unchanged
214324 General Responder Eligibility Application Form and Instruction Unchanged
214324 General Responder Eligibility Application Form and Instruction Unchanged
214323 FDNY Responder Eligibility Application Form and Instruction Unchanged
214323 FDNY Responder Eligibility Application Form and Instruction Unchanged
ICR Details
StatusActive
Agency/SubagencyHHS/CDC
OMB Control No0920-0891
Type of Information CollectionNo material or nonsubstantive change to a currently approved collection
Previous ICR Reference No202201-0920-002
Agency Tracking No0920-0891-24DA
Date Submitted to OIRA2024-02-13
Requested Expiration Date1969-12-31