Enrollment Denial Letter and Appeal Notification

Appendix Z

Enrollment Denial Letter and Appeal Notification

Form Approved

OMB No. 0920-0891

Exp. Date XXXXXX

Enrollment Denial

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

The World Trade Center (WTC) Health Program has reviewed your application for enrollment. After careful consideration of your application, I regret to inform you that we have determined that you are not eligible under the requirements specified in Sections 3311 or 3321 of Title XXXIII of the Public Health Service Act (the James Zadroga 9/11 Health and Compensation Act), 42 U.S.C. §§300mm-21 or 300mm-31.

The determination that you are not eligible was based on the following reason(s):

[Specify reason(s) why applicant was determined not to be eligible].

This determination will become final 120 calendar days from the date of this letter unless you file an appeal.

Appeal Rights

If you believe the denial of eligibility was made in error, you or your representative may appeal the denial by sending a written letter to the Administrator, WTC Health Program, at the following address: WTC Health Program, 327 Columbia Turnpike, Rensselaer, NY 12144.

The letter must be sent within 120 calendar days of the date of this letter. The information you submit with your appeal should include a complete explanation of the specific reasons you feel the denial is incorrect. A copy of your original application is included with this letter. You may include with your appeal letter any relevant information in support of your appeal which was not previously provided to the Administrator of the WTC Health Program.

Public reporting burden of this collection of information is estimated to average 30 minutes 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-xxxx).

Please note that all appeal letters must be signed. Your signature indicates that the information you provided is correct to the best of your knowledge. If you have questions about this letter or the appeal process, please send your question to the mailing address provided above or call the WTC Health Program at 1-888-982-4748.

Sincerely,

John Howard, M.D.
Administrator, World Trade Center Health Program

Enclosure:

Overview of the Appeal Process For Denial of Eligibility for Enrollment in the WTC Health Program