Request for Non-substantive Change
World Trade Center Health Program Enrollment, Petitions, Designated Representative/HIPAA Authorization, and Member Satisfaction
OMB Approval #0920-0891 – Expiration date 09/30/2025
Justification for Non-substantive change:
NIOSH is requesting a non-substantive change request for 0920-0891 to add updated information to the Appendix O and P. These forms are being updated to change the address from 395 E Street SW, Suite 9200 Washington, DC 20201, to the current address of 400 7th Street SW, Suite 5W, Washington D.C., 20024.
Existing documents being updated
Appendix O-WTC Health Program HIPAA Authorization for Deceased Individuals
Appendix P-WTC Health Program General HIPAA Authorization to Third Parties
The burden hours and costs will not be affected by these proposed changes.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Sawyer, Tamela (CDC/NIOSH/OD/ODDM) |
| File Modified | 0000-00-00 |
| File Created | 2024-09-12 |