Summary Forms_Changes

Summary of WTC Health Program Forms/Supporting Documentation and Standard Correspondence, by Type/Function

Form Type	Form Name and Appendix ID	Translations
Eligibility Applications	Appendix A: World Trade Center Health Program FDNY Responder Eligibility Application English	N/A
	Appendix B: World Trade Center Health Program Responder Eligibility Application (Other than FDNY) English	Appendix C: Spanish Appendix D: Polish
	Appendix E: World Trade Center Health Program Pentagon/Shanksville Eligibility Application	N/A
	Appendix F: World Trade Center Health Program Survivor Eligibility Application English	Appendix G: Spanish Appendix H: Polish Appendix I: Chinese
	Appendix J: General Responder Clinic Selection Postcard	N/A
Administration of Program Benefits to Eligible Members	Appendix K: Designated Representative Appointment Form	N/A
	Appendix L: Designated Representative HIPAA Authorization form	N/A
	Appendix O: WTCHP HIPAA Authorization for Deceased Individuals	N/A
	Appendix P: WTCHP General HIPAA Authorization to Third Parties	N/A
	Appendix Q: Designated Representative Revocation Form	N/A

Supplemental Documentation (Ones that were included in past burden table are now here)	Supporting Documentation Name and Appendix ID	Translations
Approval Process for Conditions, Procedures, or Medications Supported by the WTC Health Program	Appendix R: Zadroga Act (Sec 3301)	N/A
	Appendix S: Summary of Covered Health Benefits, Health Conditions, Treatments, and Payments	N/A
	Appendix T: Web Based Application Screen Shots (samples)	N/A
	Appendix U: Initial Request for Additional Information	N/A
	Appendix V: 30 Day Letter Reminder for Additional Information	N/A
	Appendix W: 60 Day Letter Reminder for Additional Information	N/A
	Appendix X: 90 Day Letter Reminder for Additional Information	N/A
	Appendix Y: 180 Day Letter Reminder for Information	N/A
	Appendix Z: WTC-5 Code or Procedure Request	N/A
	Appendix AA: WTC-3 Request for Certification	N/A
	Appendix BB: Prior Authorization Form – Standard	N/A
	Appendix CC: Prior Authorization Form – Dental	N/A
	Appendix DD: Prior Authorization Form – Transplant	N/A
	Appendix EE: Transcranial Magnetic Stimulation (TMS) Treatment Request Form	N/A
	Appendix FF: Non-Emergency General Transportation Request Form	N/A
	Appendix GG: Non-Emergency Medical Transportation Reimbursement Form	N/A
	Appendix HH: Non-Emergency Medical Transportation Request Form	N/A
	Appendix II: Prior Authorization General Level 2	N/A
	Appendix JJ: Prior Authorization General Level 3	N/A
	Appendix KK: Home Health Aid Prior Authorization Level 3	N/A
	Appendix LL: Long-term Care Hospitalization Prior Authorization Level 3	N/A
	Appendix MM In-Patient Rehabilitation Prior Authorization Level 3	N/A
	Appendix NN Hospice Respite Care Prior Authorization Level 3	N/A
	Appendix OO: Outpatient Prescription Pharmaceuticals	N/A
	Appendix PP: Enrollment Denial Letter and Appeal Notification	N/A
	Appendix QQ: Certification Denial Letter and Appeal Notification	N/A
	Appendix RR: Treatment Denial Letter and Appeal Notification	N/A
	Appendix SS-1: Federal Register Notice	N/A
	Appendix TT: IRB Determination	N/A
	Appendix UU: Translated Initial Request for Information (Spanish, Chinese, Polish)	Spanish, Chinese, Polish
	Appendix VV: Translated 30 Day Request for Information (Spanish, Chinese, Polish)	Spanish, Chinese, Polish
	Appendix WW: Translated 60 Day Request for Information (Spanish, Chinese, Polish)	Spanish, Chinese, Polish
	Appendix XX: Translated 90 Day Request for Information (Spanish, Chinese, Polish)	Spanish, Chinese, Polish
	Appendix YY: Translated 180 Day Request for Information (Spanish, Chinese, Polish)	Spanish, Chinese, Polish
	Appendix ZZ: Translated Enrollment Denial and Appeal Notification (Spanish)	Spanish
	Appendix: AAA Disenrollment Letter and Appeal Notification	N/A
	Appendix BBB: Decertification Letter Template—Administrative Error	N/A
	Appendix CCC: Decertification Letter Template—Denial and Decertification Exposure	N/A
	Appendix DDD: Decertification Letter Template—Latency Prostate Cancer/Cancer	N/A
	Appendix EEE: Overview of WTC Health Program Forms, Standard Correspondence and Changes to the Information Collection Request	N/A
	Appendix FFF: Reimbursement Denial Letter and Appeal Notification	N/A

Summary of Changes to Information Collection Forms, and Impact on Burden Estimates

Type of Respondent (with burden table line number)	Form Name	Appendix	Status	Comments	No. of Respondents	No. Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours	Change in Burden
1) FDNY Responder	World Trade Center Health Program FDNY Responder Eligibility Application	A	Modified	Revised applications that improve potential members’ application experience and reduce confusion	140	1	30/60	70	+47
2) General Responder	World Trade Center Health Program Responder Eligibility Application (Other than FDNY)	B-D	Modified	Revised applications that improve potential members’ application experience and reduce confusion	6,215	1	30/60	3,108	+1,870
3) Pentagon /Shanksville Responder	World Trade Center Health Program Pentagon/ Shanksville Responder	E	Modified	Revised applications that improve potential members’ application experience and reduce confusion	242	1	30/60	121	-194
4) WTC Survivor	World Trade Center Health Program Survivor Eligibility Application (all languages)	F-I	Modified	Revised applications that improve potential members’ application experience and reduce confusion	9,240	1	30/60	4,620	+4,020
5) General responder	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	J	Modified	Made language updates	3,830	1	15/60	958	+348
6) Program Members	Designated Representative Appointment Form	K	Modified	Revised to include instructions to fill out the form	1,300	1	15/60	325	+317
7) Program Applicants or Members	Designated Representative HIPAA Release Form	L	Modified	Revised to include instructions to fill out the form	1,300	1	15/60	325	+317
8) Interested Party	Petition for the addition of health conditions	M	No changes		35	1	1	35	-25
9) Program Members	Member Satisfaction Survey	N	New	New Survey to be mailed to all Program members one time per year	6,600	1	30/60	3,300	+3,300
10) General Public	WTC Health Program HIPAA Authorization for Deceased Individuals	O	New	New HIPAA Authorization for Deceased Individuals Form	30	1	30/60	8	+8
11) Program Applicants or Members	WTC Health Program General HIPAA Authorization to Third Parties	P	New	New HIPAA Authorization to Third Parties Form	30	1	30/60	8	+8
12) Program Applicants or Members	Designated Representative Appointment Form that removes the members current designated representative.	Q	New	New Designated Representative Revocation Form	15	1	15/60	4	+4
Total								4,963	4,277

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