World Trade Center Health Program Enrollment, Appeals & Reimbursement

ICR 202201-0920-002

OMB: 0920-0891

Federal Form Document

Forms and Documents
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Name
Status
Form and Instruction
New
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New
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New
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Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2022-01-06
Supporting Statement B
2022-01-06
Supporting Statement A
2022-01-06
Supplementary Document
2022-01-06
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
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2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-10-09
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-10-09
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
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2018-09-20
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2018-09-20
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2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
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2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
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2018-09-20
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2018-09-20
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2018-09-20
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2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2018-09-20
Supplementary Document
2014-12-18
IC Document Collections
IC ID
Document
Title
Status
251030 New
251023 New
251018 New
251017 New
233098 Modified
233096 Removed
233095 Modified
233094 Removed
233092 Removed
218099 Removed
218098 Modified
218097 Removed
218096 Modified
214337 Removed
214336 Removed
214335 Removed
214327 Removed
214326 Modified
214325 Modified
214324 Modified
214323 Modified
ICR Details
0920-0891 202201-0920-002
Received in OIRA 201703-0920-004
HHS/CDC 0920-0891
World Trade Center Health Program Enrollment, Appeals & Reimbursement
Reinstatement with change of a previously approved collection   No
Regular 01/06/2022
  Requested Previously Approved
36 Months From Approved
28,977 0
12,882 0
146,417 0

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.

PL: Pub.L. 847 - 42 88 Name of Law: Zadroga Act
  
None

Not associated with rulemaking

  86 FR 22967 04/30/2021
86 FR 70841 12/13/2021
Yes

12
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
Designated Representative Revocation Form 0920-0891 Designated Representative Revocation 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
Member Satisfaction Survey 0920-0891 Member Satisfaction Survey
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]
WTC Health Program General HIPAA Authorization to Third Parties 0920-0891 WTC Health Program HIPAA Authorization - Third Parties
WTC Health Program HIPAA Authorization for Deceased Individuals 0920-0891 WTC Health Program HIPAA Authorization - Deceased Individuals

  Total Request 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 28,977 0 0 -38,017 0 66,994
Annual Time Burden (Hours) 12,882 0 0 -1,181 0 14,063
Annual Cost Burden (Dollars) 146,417 0 0 -946,295 0 1,092,712
Yes
Miscellaneous Actions
Yes
Miscellaneous Actions
Reinstatement is submitted to remove/add forms to 0920-0891 ICR package resulting in net decrease of 1,181 Burden Hours.

$323,763
No
    Yes
    Yes
No
No
No
No
Jeffrey Zirger 404 639-7118 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/06/2022


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