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

OMB 0920-0891

The WTC Health Program is a limited healthcare program established by the James Zadroga 9/11 Health and Compensation Act of 2010. The goal of the Program is to provide monitoring and treatment to responders of the 9/11 terrorist attacks at the World Trade Center, Pentagon, and Shanksville, PA, as well as survivors in the New York City Area. The data collected contained within this OMB package are intended solely for determining eligibility and treatment.

The latest form for [NIOSH] World Trade Center Health Program Enrollment, Appeals & Reimbursement expires 2021-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 0920-0891 Designated Representative Revocation Form Form and Instruction
Form 0920-0891 Designated Representative Revocation Form Form and Instruction
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
Form 0920-0891 WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
Form 0920-0891 WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
Form 0920-0891 Member Satisfaction Survey Form and Instruction
Form 0920-0891 Member Satisfaction Survey Form and Instruction
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction
HIPAA Authorization to Release Information Form and Instruction
HIPAA Authorization to Release Information Form and Instruction
Designated Representative Form and Instruction
Designated Representative Form and Instruction
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form
Survivor Eligibility Application Form and Instruction
Survivor Eligibility Application Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
General Responder Eligibility Application Form and Instruction
General Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form and Instruction
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change
Request for Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document
App Y 180 Day Letter Reminder for Additional Information.docx Supplementary Document
App X Survivor 90 Day Suspend Letter.docx Supplementary Document
App X Survivor 90 Day Suspend Letter.docx Supplementary Document
App W 60 Day Suspend Letter.docx Supplementary Document
App W 60 Day Suspend Letter.docx Supplementary Document
App V 30 Day Suspend Letter.docx Supplementary Document
App V 30 Day Suspend Letter.docx Supplementary Document
App U Initial Request for Additional Information.docx Supplementary Document
App U Initial Request for Additional Information.docx Supplementary Document
App ZZ Disenrollment Letter.docx Supplementary Document
App ZZ Disenrollment Letter.docx Supplementary Document
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document
App RR Treatment Denial Letter and Appeal Notification.docx Supplementary Document
App QQ Certification Denial Letter and Appeal.docx Supplementary Document
App QQ Certification Denial Letter and Appeal.docx Supplementary Document
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document
App PP Enrollment Denial Letter and Appeal Notification.docx Supplementary Document
App AAA Decert Letter Template Admin Error.docx Supplementary Document
App AAA Decert Letter Template Admin Error.docx Supplementary Document
App DDD Summary of Forms and Changes.docx Supplementary Document
App DDD Summary of Forms and Changes.docx Supplementary Document
SSB-Update-91321.docx Supporting Statement B
SSB-Update-91321.docx Supporting Statement B
SSA-Update-091321.docx Supporting Statement A
SSA-Update-091321.docx Supporting Statement A
60d FRN published.pdf Supplementary Document
60d FRN published.pdf Supplementary Document
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document
App Y-11. NF PA3 Opioid Deterrent_09242018.pdf Supplementary Document
App Y-10. NF PA3 Nucala.pdf Supplementary Document
App Y-10. NF PA3 Nucala.pdf Supplementary Document
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document
App Y-9. NF PA3 Methadone_09242018.pdf Supplementary Document
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document
App Y-8. NF PA3 Diabetes Insulin_09242018.pdf Supplementary Document
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document
App Y-7. NF PA3 Epinephrine.pdf Supplementary Document
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document
App Y-6. NF PA3 Antipsychotics.pdf Supplementary Document
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document
App Y-5. NF PA3 Antiemetics.pdf Supplementary Document
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document
App Y-4. NF PA3 Antidepressants.pdf Supplementary Document
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document
App Y-3. NF PA3 Airway Drugs.pdf Supplementary Document
App Y-2. PA3 Renewal Form.pdf Supplementary Document
App Y-2. PA3 Renewal Form.pdf Supplementary Document
App Y-1. General PA3 Form.pdf Supplementary Document
App Y-1. General PA3 Form.pdf Supplementary Document
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document
App TT Reimbursement Appeal Decision Letter.docx Supplementary Document
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document
CDC-WTCHP-1741-PTA-08-28-2018-100....pdf Supplementary Document
App SS Summary of Forms and Changes_100918.docx Supplementary Document
App SS Summary of Forms and Changes_100918.docx Supplementary Document
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document
App RR Decert Letter Template_Latency_Prostate_Cancer.docx Supplementary Document
App PP Disenrollment and Decert Template.docx Supplementary Document
App PP Disenrollment and Decert Template.docx Supplementary Document
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document
App KK Translated Enroll Denial and Appeal Notif-Span.docx Supplementary Document
App JJ - Translated 180 Day Request for Information.docx Supplementary Document
App JJ - Translated 180 Day Request for Information.docx Supplementary Document
App II - Translated 90 Day Request for Information.docx Supplementary Document
App II - Translated 90 Day Request for Information.docx Supplementary Document
App HH - Translated 60 Day Request for Information.docx Supplementary Document
App HH - Translated 60 Day Request for Information.docx Supplementary Document
App GG - Translated 30 Day Request for Information.docx Supplementary Document
App GG - Translated 30 Day Request for Information.docx Supplementary Document
App FF - Translated Initial Request for Information.docx Supplementary Document
App FF - Translated Initial Request for Information.docx Supplementary Document
App EE IRB Determination.pdf Supplementary Document
App EE IRB Determination.pdf Supplementary Document
App DD-1 60-day FRN 05112018.pdf Supplementary Document
App DD-1 60-day FRN 05112018.pdf Supplementary Document
App X Prior Authorization Form_Transplant.pdf Supplementary Document
App X Prior Authorization Form_Transplant.pdf Supplementary Document
App W Prior Authorization Form_Dental.pdf Supplementary Document
App W Prior Authorization Form_Dental.pdf Supplementary Document
App V Prior Authorization Form_Standard.pdf Supplementary Document
App V Prior Authorization Form_Standard.pdf Supplementary Document
App U WTC6 Medication Request.pdf Supplementary Document
App U WTC6 Medication Request.pdf Supplementary Document
App T WTC_5 Code or Procedure Request.pdf Supplementary Document
App T WTC_5 Code or Procedure Request.pdf Supplementary Document
App Q 180 Day Letter Requesting Information.docx Supplementary Document
App Q 180 Day Letter Requesting Information.docx Supplementary Document
App P 90 Day Letter Requesting Information.docx Supplementary Document
App P 90 Day Letter Requesting Information.docx Supplementary Document
App O 60 Day Letter Requesting Information.docx Supplementary Document
App O 60 Day Letter Requesting Information.docx Supplementary Document
App N 30 Day Letter Requesting Information.docx Supplementary Document
App N 30 Day Letter Requesting Information.docx Supplementary Document
App M Initial Letter Requesting Information.docx Supplementary Document
App M Initial Letter Requesting Information.docx Supplementary Document
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document
App B Summary of Covered Hlth Ben-Cond-Tx-Pay.docx Supplementary Document
Appendix A Legislation.docx Supplementary Document
Appendix A Legislation.docx Supplementary Document
Designated Representative Revocation Form Form and Instruction
Designated Representative Revocation Form Form and Instruction
WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
WTC Health Program General HIPAA Authorization to Third Parties Form and Instruction
WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
WTC Health Program HIPAA Authorization for Deceased Individuals Form and Instruction
Member Satisfaction Survey Form and Instruction
Member Satisfaction Survey Form and Instruction
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Form and Instruction
HIPAA Authorization to Release Information Form and Instruction
HIPAA Authorization to Release Information Form and Instruction
Designated Representative Form and Instruction
Designated Representative Form and Instruction
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Form
Survivor Eligibility Application Form and Instruction
Survivor Eligibility Application Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
Pentagon / Shanksville Responder Form and Instruction
General Responder Eligibility Application Form and Instruction
General Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form and Instruction
FDNY Responder Eligibility Application Form and Instruction

All Historical Document Collections

202402-0920-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-02-13
202201-0920-002 Approved without change	Reinstatement with change of a previously approved collection	2022-01-06
201703-0920-004 Approved without change	Revision of a currently approved collection	2018-09-25
201412-0920-012 Approved with change	Revision of a currently approved collection	2014-12-30
201406-0920-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2014-06-05
201307-0920-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-07-01
201112-0920-016 Approved without change	No material or nonsubstantive change to a currently approved collection	2011-12-27
201112-0920-010 Approved without change	Extension without change of a currently approved collection	2011-12-16
201112-0920-007 Approved without change	Revision of a currently approved collection	2011-12-13
201106-0920-016 Preapproved	New collection (Request for a new OMB Control Number)	2011-06-27

OMB Details

FDNY Responder Eligibility Application

Federal Enterprise Architecture: Health - Health Care Services

Form n/a	FDNY Responder Eligibility Application	Fillable Fileable	Form and instruction
Form n/a	Screen shots of Web interface for electronic reporting option	Fillable Fileable	Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.