0920-0891 WTCHP Designated Representative Form_10FEB2025

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

Designated Representative Appointment Form
As an applicant to or member of the World Trade Center (WTC) Health Program, you may appoint an individual to be
your Designated Representative. Your Designated Representative is authorized to act on your behalf and represent
your interests in the WTC Health Program. A Designated Representative is allowed to provide and obtain personal
information regarding your application to the WTC Health Program, your care, and your membership in the Program,
and may make a request or give direction to the Program regarding your eligibility, certification, or any other
administrative issue under the WTC Health Program, including appeals.
A Designated Representative can be anyone such as a family member, advocate, attorney, or friend, unless that
individual’s service as a representative would violate any applicable provision of law or is otherwise prohibited by
WTC Health Program policies and procedures or contract provisions.11 A parent or guardian may act on behalf of
a minor. If an applicant or WTC Health Program member is a mentally incompetent adult, an individual authorized
under state or other applicable law to act on the applicant’s or member’s behalf may act as his or her Designated
Representative.
You may have appointed a healthcare proxy or assigned a healthcare power of attorney to a family member or
other person so that they may obtain, use, and disclose your personal information, and/or make medical treatment
decisions on your behalf. Please note that a healthcare proxy/power of attorney is different from a Designated
Representative. Your Designated Representative within the WTC Health Program may not make medical care
(e.g., treatment) decisions on your behalf. If you have already appointed someone to act on your behalf regarding
healthcare decisions and you would like for that person to also serve as your Designated Representative for purposes
of the WTC Health Program, please complete this form.
Please note, a Designated Representative also differs from any attorney or licensed representative involved in any
workers’ compensation or other worker-related injury or illness claim you may have.
An individual’s Designated Representative must be properly appointed in writing. The WTC Health Program will only
recognize one Designated Representative at a given time. Once a Designated Representative has been properly
appointed, the WTC Health Program will not recognize another individual as your Designated Representative until
the appointment of the first Designated Representative is withdrawn in writing. In addition to this form, in order
to duly appoint a Designated Representative for the WTC Health Program, you must also submit the WTC Health
Program HIPAA Authorization for Designated Representatives Form.
If you have previously appointed a Designated Representative for the WTC Health Program and want to remove or
change your Designated Representative, please also fill out the Designated Representative Revocation Form.
By appointing a Designated Representative, you are authorizing the WTC Health Program to disclose your member
information to your Designated Representative and authorizing that individual to do the following:


Serve as your representative in all matters pertaining to your membership in the WTC Health Program; and



Receive and/or provide information pertaining to your membership and participation in the WTC Health
Program, including copies of factual and medical evidence contained in your records for the Program.

Any notice requirement of the WTC Health Program is fully satisfied if sent to your Designated Representative.

1 See WTC Health Program regulations at 42 CFR 88.2(a). A Federal employee may act as a representative only on behalf of the individuals
specified in, and in the manner permitted by, 18 U.S.C. §§ 203 and 205 (permitting self-representation and representation of a parent, spouse or
child of the employee; or a person or estate of which the employee serves as a guardian, executor, administrator, trustee or personal fiduciary).
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 H21-8, Atlanta, Georgia 30333; ATTN: PRA (0920-0891).

Designated Representative Appointment Form

INSTRUCTIONS: This form is for use when a World Trade Center (WTC) Health Program applicant or member wants
to appoint a Designated Representative to represent their interests under the Program. If you choose to submit this
form, it must be in addition to a WTC Health Program HIPAA Authorization for Designated Representatives Form.
This form must be filled out in its entirety by the WTC Health Program applicant or member. If you already have a
Designated Representative and want to remove or change your Designated Representative, please also fill out the
Designated Representative Revocation Form.
Please return all documents to the WTC Health Program via mail ATTN: WTC Health Program Privacy Officer at
P.O. Box 7000 Rensselaer, NY 12144 or via fax at 404-448-4485.
If you would like to authorize a Designated Representative to act on your behalf in matters related to your WTC
Health Program application and/or membership, please provide the following information:

First & Last Name of the Designated Representative
Your Relationship to the Designated Representative (e.g., spouse, parent-child, attorney-client)

Mailing Address of the Designated Representative:
Street:
City:

Street 2:

State:

Zip Code:

Designated Representative’s Primary Phone Number: ( ) -
Designated Representative’s Email Address:
F I have already or will submit a HIPAA Authorization for Designated Representatives Form.
Please read the following statement before signing the form:
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. This designation is effective on the date it is signed.

Printed Name of Applicant/Member

Date of Birth

Address

WTC Health Program ID (911#), if known

Address Line 2

Phone

Applicant/Member Signature

Date