0920-0891 General HIPAA Authorization for Disclosures to Third Par

OMB No. 0920-0891
Exp. Date 09/30/2025

General HIPAA Authorization for Disclosures to Third Parties
INSTRUCTIONS: If you would like the World Trade Center (WTC) Health Program to provide your protected health
information to a third party, you may authorize such disclosure by submitting this form. This form must be filled out
in its entirety by the WTC Health Program applicant or member or their personal representative. In addition to the
form itself, please include:


Documentation verifying the identity of the recipient, such as a copy of a driver’s license or other government
identification, if you are requesting records to be sent to a third party.



(Personal Representatives ONLY) Documentation demonstrating your legal authority to act on behalf of the
applicant or member, such as a copy of a Power of Attorney authorization, and documentation verifying your
identity as the personal representative, such as a copy of a driver’s license.

Please return all documents to the WTC Health Program via mail ATTN: WTC Health Program Privacy Officer
at 400 7th Street SW, Suite 5W, Washington D.C., 20024 or via fax at 404-448-4485.
I,
, give permission to the U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and
Health (NIOSH), World Trade Center (WTC) Health Program11 to disclose the following protected health information
related to:

(NAME OF APPLICANT/MEMBER AND WTC HEALTH PROGRAM ID (911#), IF KNOWN)

(DATE OF BIRTH OF APPLICANT/MEMBER)

To the following individual or entity:

(NAME OF RECIPIENT)

(ADDRESS OF RECIPIENT)

(TELEPHONE NUMBER OF RECIPIENT)

(EMAIL ADDRESS OF RECIPIENT, IF KNOWN)

1 For purposes of this document, all references to the WTC Health Program include NIOSH to the extent that it administers the WTC Health
Program, as well as all contractors who are business associates of the WTC Health Program and conduct activities on behalf of the WTC Health
Program, including but not limited to the Clinical Centers of Excellence and Nationwide Provider Network.
Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection
Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0891).

Page 1 of 3

General HIPAA Authorization for Disclosures to Third Parties

For the following purpose:
The information to be disclosed will be the minimum necessary for the third party to carry out its purpose and may
include (please check all that apply and describe if there are any exclusions within each checked category):
F WTC Health Program certification decision letters, including certification denial decisions/letters (This letter
lists conditions for which the WTC Health Program has determined are related to or medically associated
with the member’s 9/11 exposures)
Please list any exclusions to the WTC Health Program’s disclosure of its certification decisions/letters:

F WTC Health Program enrollment decision letters (This letter confirms a member’s successful enrollment
in the WTC Health Program) and application materials (documents that the WTC Health Program used to
determine the individual’s eligibility for enrollment)
Please list any exclusions to the WTC Health Program’s disclosure of its enrollment application materials:

And, if requested:
F Medical Records, including treatment and diagnostic records. Please note that medical records requests will
be forwarded to the member’s clinic for fulfillment.
Please list any exclusions to the WTC Health Program’s disclosure of its Medical Records:

F Other Records:
Please list any exclusions to the WTC Health Program’s disclosure of its Other Records:

F Other Exclusions:
This authorization expires when the information requested is provided to the above-named recipient, or at such
time as I exercise my right to revoke this authorization in writing, whichever happens earlier. I may revoke this
authorization in writing at any time by sending written notification to the Program: ATTN: WTC Health Program
Privacy Officer 395 E Street SW, Suite 9200 Washington, DC 20201. Use or disclosure of my protected health
information by the WTC Health Program made prior to the Program’s receipt of my written request to revoke this
authorization will be governed by this authorization to the extent that the Program has taken any action in reliance on
this authorization already.
Signing this authorization is voluntary. The WTC Health Program may not condition treatment, payment, enrollment,
or eligibility for benefits on the signing of this authorization, as applicable. The information disclosed under this
authorization may be subject to further disclosure by the authorized recipient(s); such additional disclosures by third
parties are not subject to, nor protected by, this authorization. The WTC Health Program will give me a copy of this
signed authorization, upon request. (Requests may be made in writing to the above address.)

Page 2 of 3

General HIPAA Authorization for Disclosures to Third Parties

I hereby authorize the WTC Health Program to disclose the above-described health information to

, for the above-described purpose(s).

(NAME OF RECIPIENT)

By my signature I attest that I have provided truthful and accurate information and that I understand the following:
Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of
fraud to the United State Government is subject to civil and/or administrative remedies as well as felony criminal
prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both pursuant
to 18 U.S.C. § 1001.

Printed Name of Applicant/Member

Date of Birth

Address

WTC Health Program ID (911#), if known

Address Line 2

Phone

Applicant/Member Signature

Date

Page 3 of 3