WTC Health Program HIPAA Authorization for Deceased Individuals

[NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement

OMB: 0920-0891

IC ID: 251018

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

WTC Health Program HIPAA Authorization for Deceased Individuals
 
No Unchanged
 
Required to Obtain or Retain Benefits
 

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 - Deceased Individuals App O WTCHP HIPAA Authorization for Deceased Individuals DRAFT.docx NA Yes Yes Fillable Fileable
Form and Instruction 0920-0891 HIPAA Authorization for Disclosures Regarding Deceased Individuals App-O-WTCHP-HIPAA-Authorization-for-Deceased-Individuals-updated2024.pdf N/A Yes Yes Fillable Fileable

Health Health Care Services

09-20-0147 Occupational Health Epidemiological Studies and EEOICPA Program Records and WTC Health Program Records  76 FR 34706

30 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 30 0 0 0 0 30
Annual IC Time Burden (Hours) 8 0 0 0 0 8
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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