HIPAA Authorization to Release Information

World Trade Center Health Program Enrollment, Appeals & Reimbursement

OMB: 0920-0891

IC ID: 233095

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HIPAA Authorization to Release Information
 
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Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction n/a HIPAA Authorization Form to Release Information App MM WTC HIPAA Form.docx No   Paper Only

Health Health Care Services

09-20-0147 Occupational Health Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records HHS/CDC/NIOSH  76 FR 34706

30 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 30 0 30 0 0 0
Annual IC Time Burden (Hours) 8 0 8 0 0 0
Annual IC Cost Burden (Dollars) 137 0 137 0 0 0

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