Justification for WTC Change 12_23_2011

Justification for Change

0920-0891-World Trade Center Health Program Enrollment, Appeals, & Reimbursement (Expiration 12/31/2014)

The purpose of this nonmaterial/non-substantive change request is to add the WTC Health Condition Certification Request form which was mistakenly left off of one of the Part 2 forms. This WTC Health Condition Certification Request form is referenced on pages 5, 7 and 9 of the supporting statement. The burden hours are accounted for in the burden table.

This form is essential because healthcare providers will submit a request that the Program to certify an enrolled participant's health condition. The certification request may include, but may not be limited to, the following data elements: exposure assessment summary, mental health assessment summary, date of enrollment, medical diagnosis of WTC-related health condition, and recordkeeping (including exposure assessment, medical history, physical and/or mental status exam findings, and specific medical testing finding). This form is Attachment J.