Pharmacy - Outpatient Prescription Pharmaceuticals

World Trade Center Health Program Enrollment, Appeals & Reimbursement

App Y. Outpatient Prescription Pharmaceuticals

Pharmacy - Outpatient Prescription Pharmaceuticals

OMB: 0920-0891

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Appendix HH Outpatient Prescription Pharmaceuticals



Form Approved

OMB No. 0920-0891

Exp. Date XXXXXX



This is a mock form to account for the burden incurred from the electronic submission of the Outpatient prescription pharmaceuticals.

















Public reporting burden of this collection of information is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0891).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCDC User
File Modified0000-00-00
File Created2021-01-20

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