30-day Letter Requesting Information

Appendix N

30 Day Letter Requesting Additional Information

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

Your application to enroll in the World Trade Center (WTC) Health Program remains incomplete.

We cannot process your application until we receive needed information from you. 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