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WTC Health Program General HIPAA Authorization to Third Parties
World Trade Center Health Program Enrollment, Appeals & Reimbursement
OMB: 0920-0891
IC ID: 251023
OMB.report
HHS/CDC
OMB 0920-0891
ICR 202201-0920-002
IC 251023
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:
2024-02-13 - No material or nonsubstantive change to a currently approved collection
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
View Information Collection (IC)
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
Federal Enterprise Architecture Business Reference Module
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 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)
0
0
0
0
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.