WTC Health Program General HIPAA Authorization to Third Parties

World Trade Center Health Program Enrollment, Appeals & Reimbursement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
0920-0891 WTC Health Program HIPAA Authorization - Third Parties App P WTCHP General HIPAA Authorization to Third Parties DRAFT.docx Form and Instruction
0920-0891 WTC Health Program HIPAA Authorization - Third Parties App P WTCHP General HIPAA Authorization to Third Parties DRAFT.docx Form and Instruction

Information Collection (IC) Details

IC Title:	WTC Health Program General HIPAA Authorization to Third Parties	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0891	WTC Health Program HIPAA Authorization - Third Parties	App P WTCHP General HIPAA Authorization to Third Parties DRAFT.docx	NA	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: 09-20-0147 Occupational Health Epidemiologic Studies and EEOICPA Program Records and WTC Health Program Records	FR Citation: 76 FR 34706

Number of Respondents: 30	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.