World Trade Center Health Program Enrollment, Appeals & Reimbursement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Petition for the addition of health conditions	Form and Instruction	New	Available
Reimbursement Denial Letter and Appeal Notification - Providers	Form and Instruction	New	Available
HIPAA Authorization Form to Release Information	Form and Instruction	New	Available
Decertification Letter and Appeal Notification - Health Condition	Form and Instruction	New	Available
Disenrollment Letter and Appeal Notification	Form and Instruction	New	Available
Designated Representative Form	Form and Instruction	Modified	Available
Request for Certification of a WTC Related Health Condition	Form and Instruction	Modified	Available
Clinic Selection Postcard	Form	Modified	Available
Medical Travel Refund Request	Form and Instruction	Modified	Available
Denial Letter and Appeal Notification for Treatment Authorization	Form and Instruction	Modified	Available
Denial Letter and Appeal Notification - Health Condition Certification	Form and Instruction	Modified	Available
Enrollment Denial Letter and Appeal Notification	Form and Instruction	Modified	Available
Eligibility Application for Survivors [Chinese]	Form and Instruction	Modified	Available
Eligibility Application for Survivors [Polish]	Form and Instruction	Modified	Repair queued
Eligibility Application for Survivors [Spanish]	Form and Instruction	Modified	Available
Eligibility Application for Survivors [English]	Form and Instruction	Modified	Available
Pentagon / Shanksville Responder Eligibility Application	Form and Instruction	Modified	Repair queued
General Responder (other than FDNY) Eligibility Application [Polish]	Form and Instruction	Modified	Repair queued
General Responder (other than FDNY) Eligibility Application [Spanish]	Form and Instruction	Modified	Available
General Responder (other than FDNY) Eligibility Application [English]	Form and Instruction	Modified	Available
Screen shots of Web interface for electronic reporting option	Form	Modified	Available
FDNY Responder Eligibility Application	Form and Instruction	Modified	Available
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf	Supplementary Document	Uploaded 2018-10-09	Available
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	Available
App Y-7. NF PA3 Epinephrine.pdf	Supplementary Document	Uploaded 2018-10-09	Available
App Y-6. NF PA3 Antipsychotics.pdf	Supplementary Document	Uploaded 2018-10-09	Available
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	Available
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	Available
App RR Decert Letter Template_Latency_Prostate_Cancer.docx	Supplementary Document	Uploaded 2018-09-20	Available
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	Available
App JJ - Translated 180 Day Request for Information.docx	Supplementary Document	Uploaded 2018-09-20	Available
App II - Translated 90 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	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	Available
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	Available
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	Available
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	Available
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

Information collection document groups

IC ID	Collection	Type	Status	Form
233098	Petition for the Addition of a Health Condition (previously approved under 0920-0929)	Form and Instruction	New	Petition for the addition of health conditions
233096	Reimbursement Denial Letter and Appeal Notification - Providers	Form and Instruction	New	Reimbursement Denial Letter and Appeal Notification - Providers
233095	HIPAA Authorization to Release Information	Form and Instruction	New	HIPAA Authorization Form to Release Information
233094	Decertification Letter and Appeal Notification for a Health Condition	Form and Instruction	New	Decertification Letter and Appeal Notification - Health Condition
233092	Disenrollment and Appeal Process for Responders	Form and Instruction	New	Disenrollment Letter and Appeal Notification
218099	Pharmacy - Outpatient Prescription Pharmaceuticals	Other-Dummy Form Representing an Electronic Data Transfer	Modified
218098	Designated Representative	Form and Instruction	Modified	Designated Representative Form
218097	Request for Certification of Health Condition (WTC-3)	Form and Instruction	Modified	Request for Certification of a WTC Related Health Condition
218096	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	Form	Modified	Clinic Selection Postcard
214337	Responder Medical Travel Refund Request	Form and Instruction	Modified	Medical Travel Refund Request
214336	Responder Denial Ltter and Appeal Notification - Treatment	Form and Instruction	Modified	Denial Letter and Appeal Notification for Treatment Authorization
214335	Responder Denial and Appeal - Health Conditions	Form and Instruction	Modified	Denial Letter and Appeal Notification - Health Condition Certification
214327	Responder Denial and Appeal - Eligibility	Form and Instruction	Modified	Enrollment Denial Letter and Appeal Notification
214326	Survivor Eligibility Application	Form and Instruction	Modified	Eligibility Application for Survivors [Chinese]
214326	Survivor Eligibility Application	Form and Instruction	Modified	Eligibility Application for Survivors [Polish]
214326	Survivor Eligibility Application	Form and Instruction	Modified	Eligibility Application for Survivors [Spanish]
214326	Survivor Eligibility Application	Form and Instruction	Modified	Eligibility Application for Survivors [English]
214325	Pentagon / Shanksville Responder	Form and Instruction	Modified	Pentagon / Shanksville Responder Eligibility Application
214324	General Responder Eligibility Application	Form and Instruction	Modified	General Responder (other than FDNY) Eligibility Application [Polish]
214324	General Responder Eligibility Application	Form and Instruction	Modified	General Responder (other than FDNY) Eligibility Application [Spanish]
214324	General Responder Eligibility Application	Form and Instruction	Modified	General Responder (other than FDNY) Eligibility Application [English]
214323	FDNY Responder Eligibility Application	Form	Modified	Screen shots of Web interface for electronic reporting option
214323	FDNY Responder Eligibility Application	Form and Instruction	Modified	FDNY Responder Eligibility Application

ICR Details

OMB Control No: 0920-0891	ICR Reference No: 201703-0920-004
Status: Historical Active	Previous ICR Reference No: 201412-0920-012
Agency/Subagency: HHS/CDC	Agency Tracking No: 19888
Title: World Trade Center Health Program Enrollment, Appeals & Reimbursement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/03/2018
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/25/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2021	36 Months From Approved	11/30/2018
Responses	66,994	0	66,276
Time Burden (Hours)	14,063	0	13,594
Cost Burden (Dollars)	1,092,712	0	0

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Abstract: 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.

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Authorizing Statute(s): PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 22067	05/11/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 48428	09/25/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

table that charts list of burden

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
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
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]

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ICR Summary of Burden

table that charts list of burden

	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

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: 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.

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Annual Cost to Federal Government: $1,080,300

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 09/25/2018

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