Information Collection

WTC Health Program General HIPAA Authorization to Third Parties

IC 251023 under ICR 202402-0920-004 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties	Form and Instruction
Form 0920-0891 WTC Health Program HIPAA Authorization - Third Parties WTC Health Program General HIPAA Authorization to Third Parties	Form and Instruction
Form 0920-0891 General HIPAA Authorization for Disclosures to Third Parties 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
0920-0891 General HIPAA Authorization for Disclosures to Third Par App-P-WTCHP-General-HIPAA-Authorization-to-Third-Parties-updated2024.pdf	Form and Instruction
0920-0891 General HIPAA Authorization for Disclosures to Third Par App-P-WTCHP-General-HIPAA-Authorization-to-Third-Parties-updated2024.pdf	Form and Instruction

IC Title:

WTC Health Program General HIPAA Authorization to Third Parties

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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
Form and Instruction	0920-0891	General HIPAA Authorization for Disclosures to Third Parties	App-P-WTCHP-General-HIPAA-Authorization-to-Third-Parties-updated2024.pdf	N/A	Yes	Yes	Fillable Fileable

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30	30
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.