Summary of Forms and Changes in the ICR

Summary of WTC Health Program Forms and Standard Correspondence, by Type/Function

Form Type	Form Name and Appendix ID	Translations
Eligibility Applications	Appendix C: World Trade Center Health Program FDNY Responder Eligibility Application English
	Appendix D: World Trade Center Health Program Responder Eligibility Application (Other than FDNY) English	Appendix E: Spanish Appendix F: Polish
	Appendix G: World Trade Center Health Program Pentagon/Shanksville Eligibility Application
	Appendix H: World Trade Center Health Program Survivor Eligibility Application English	Appendix I: Spanish Appendix J: Polish Appendix K: Chinese
	Appendix L: Web based Application Screen Shots
Additional Information Needed to Assess Eligibility	Appendix M: Initial Request for Additional Information	Appendix FF: Translations initial request (Spanish, Chinese, Polish)
	Appendix N: 30 Day Letter Reminder for Additional Information	Appendix GG: Translations 30 day request (Spanish, Chinese, Polish)
	Appendix O: 60 Day Letter Reminder for Additional Information	Appendix HH: Translations 60 day request (Spanish, Chinese, Polish)
	Appendix P: 90 Day Letter Reminder for Additional Information	Appendix II: Translations 90 day request (Spanish, Chinese, Polish)
	Appendix Q: 180 Day Letter Reminder for Additional Information	Appendix JJ: Translations 180 day request (Spanish, Chinese, Polish)
Denials and Appeals	Appendix Z: Enrollment Denial Letter and Appeal Notification	Appendix KK: Spanish
	Appendix AA: Certification Denial Letter and Appeal Notification
	Appendix BB: Treatment Denial Letter and Appeal Notification
	Appendix PP Decertification Letter Template—Administrative Error
	Appendix QQ Decertification Letter Template—Denial and Decertification Exposure
	Appendix RR Decertification Letter Template—Latency Prostate Cancer/Cancer
	Appendix OO: Disenrollment Letter and Appeal Notification
	Appendix TT: Reimbursement Denial Letter and Appeal Notification
Administration of Program Benefits to Eligible Members	Appendix R: Clinic Selection Postcard
	Appendix V: Prior Authorization Form – Standard
	Appendix W: Prior Authorization Form – Dental
	Appendix X: Prior Authorization Form – Transplant
	Appendix CC: WTC Health Program Medical Travel Refund Request
	Appendix LL: Designated Representative Form
	Appendix MM: HIPAA Release

Approval Process for Conditions, Procedures, or Medications Supported by the WTC Health Program	Appendix S: WTC-3 Request for Certification
	Appendix T: WTC-5 Code or Procedure Request
	Appendix U: WTC-6 Medication Request for Codebook
	Appendix NN: Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program Form
	Appendix DD: 1 Federal Register Notice
	Appendix EE: IRB Determination
	Appendix Y: Outpatient Prescription Pharmaceuticals
	Appendix Y-1: Non Formulary Prior Authorization – Prescription (General)
	Appendix Y-2 Non-Formulary Prior Authorization – Prescription (Renewal)
	Appendix Y-3 Non-Formulary Prior Authorization – Airway Medication
	Appendix Y-4 Non-Formulary Prior Authorization – Antidepressant
	Appendix Y-5 Non-Formulary Prior Authorization – Antiemetic
	Appendix Y-6 Non-Formulary Prior Authorization – Antipsychotic
	Appendix Y-7 Non-Formulary Prior Authorization – Epinephrine
	Appendix Y-8 Non-Formulary Prior Authorization – Insulin
	Appendix Y-9 Non-Formulary Prior Authorization –Methadone
	Appendix Y-10 Non-Formulary Prior Authorization – Nucala
	Appendix Y-11 Non-Formulary Prior Authorization – Opioid Abuse

Summary of Changes to Information Collection Forms, and Impact on Burden Estimates

Type of Respondent (with burden table line number)	Form Name	Appendix	Status	Comments	No. of Respondents	No. Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours	Change in Burden
1) FDNY Responder	World Trade Center Health Program FDNY Responder Eligibility Application	C	No change		45	1	30/60	23	0
2) General Responder	World Trade Center Health Program Responder Eligibility Application (Other than FDNY)	D, E, F	Modified	No change to form content or burden, but translations were added	2,475	1	30/60	1,238	0
3) Pentagon/ Shanksville Responder	World Trade Center Health Program Pentagon/ Shanksville Responder	G	No change		630	1	30/60	315	0
4) WTC Survivor	World Trade Center Health Program Survivor Eligibility Application (all languages)	H, I, J, K	Modified	No change to form content or burden, but translations were added	1,350	1	30/60	675	0
5) General responder	Clinic Selection Postcard for new general responders in NY/NJ to select a clinic	R	No change		2,475	1	15/60	619	0
6) Program Medical Provider	Physician Request for Certification (WTC-3)	S	No change		20,000	1	30/60	10,000	0
7) Responder (FDNY and General Responder)/ Survivor	Denial Letter and Appeal Notification – Enrollment	Z	No change		45	1	30/60	23	0
8) Responder (FDNY and General Responder)/ Survivor	Disenrollment Letter and Appeal Notification – Enrollment	OO	New	Changes due to 42 CFR 88.14	3	1	30/60	2	+2
9) Responder (FDNY and General Responder)/ Survivor	Decertification Letter and Appeal Notification – Health Condition	QQ	New	Changes due to 42 CFR 88.21	5	1	1.5	8	+8
10) Responder (FDNY and General Responder)/ Survivor	Denial Letter and Appeal Notification – Health Condition Certification	AA	Modified	Due to clarification in 42 CFR 88.21, burden per response increased from 30 min to 90 min with resulting increase in total	60	1	1.5	90	+60
11) Responder (FDNY and General Responder)/Survivor	Denial Letter and Appeal Notification – Treatment Authorization	BB	Modified	Clarification of right to appeal under 42 CFR 88.21; burden per response increased from 30 min to 90 min with resulting change in total	26	1	1.5	39	+26
12) Responder (FDNY and General Responder)/Survivor	WTC Health Program Medical Travel Refund Request	CC	No change		10	1	10/60	2	0
13) Program Members	Designated Representative Form	LL	Modified	Form was modified but no change in average burden per response; number of forms increased resulting in increase in total burden	30	1	15/60	8	+5
14) Program Member	HIPAA Release Form to allow the sharing of member information with a third party	MM	New	This is a program-initiated change that allows the WTC program to interface with third parties	30	1	15/60	8	+8
15) Pharmacy	Outpatient prescription pharmaceuticals	Y	Form updated; No change to burden estimates		150	261	1/60	653	0
16) Program Medical Provider	Reimbursement Denial Letter and Appeal Notification – Providers	TT	New	New appeals process under 88.23 Generated at CCE/NPN level	600	1	30/60	300	+300
17) Responder/ Survivor/ Advocate (physician)	Petition for the addition of health conditions	NN	Modified	Migrated from 0920-0929	60	1	1	60	+60
Total								14,063	+469

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