Initial Letter Requesting Information

Appendix M

Initial Letter Requesting Additional Information

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

Thank you for submitting an application to enroll in the World Trade Center (WTC) Health Program. We received your enrollment application and assigned it the following number [Member ID #].

We cannot process your application at this time because it is missing needed information. If you have already received a telephone call about the needed information, this letter is meant as a reminder.

Please provide the Enrollment Center the following information at your earliest convenience:

[Specify exactly what information is needed from the applicant]

Missing information may be faxed to 1-877-646-5308, or mailed to:

WTC Health Program

PO Box 7000

Rensselaer, NY 12144

If you have questions about the WTC Health Program or need any assistance in providing the information we request:

Call your Enrollment Center Specialist at [TELEPHONE NUMBER]. If you are unable to reach your Enrollment Center Specialist, call us at 1-888-982-4748, Monday through Friday, 9 AM to 5 PM (Eastern Time Zone) or visit the WTC Health Program website at: http://www.cdc.gov/wtc.

Sincerely,

[NAME]

Enrollment Center Specialist

WTC Health Program