180-day Letter Requesting Information

Appendix Q

180 Day Letter Requesting Additional Information

Re: <Member ID#>

<Date>

Dear <First Name> <Last Name>:

On [INSERT DATE 90-DAY REMINDER/WARNING LETTER SENT], the World Trade Center (WTC) Health Program Enrollment Center sent you a letter informing you that your application for enrollment in the WTC Health Program was missing necessary information and would be marked “inactive” unless we receive communication from you within 90 calendar days.

We have not received any communication from you in the 90 days since our last letter to you. The WTC Health Program Enrollment Center has marked your application “inactive.”

Please be aware that at this time (1) you are not an enrolled member of the WTC Health Program; and (2) you are not currently eligible for WTC Health Program benefits.

The Enrollment Center will retain your current application on file for the duration of the WTC Health Program. If we receive communication from you, we will reactivate your application.

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 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,

Enrollment Center Coordinator

WTC Health Program