OMB control number
World Trade Center Health Program Enrollment & Appeals - Pentagon & Shanksville, PA Responders
OMB 0920-0962 ยท HHS/CDC.
OMB 0920-0962
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Medical Travel Refund Request | Form |
 Form SF 3881 SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form | Form |
| WTC Pentagon & Shanksville, PA Eligibility Application | Form |
| Appendix A Zadroga Act.docx | Supplementary Document |
| Denial Letter Health Condition F-1.docx | Supplementary Document |
| Denial Letter G-1 - Treatment.docx | Supplementary Document |
| Denial Letter C-1 - Eligibility.docx | Supplementary Document |
| World Trade Center Supptg Stmt A PA_VA application 3.29.13.docx | Supporting Statement A |
 Medical Travel Refund Request |
Form |
| Outpatient Pharmacies |
Other-Document |
| SF 3881 ACH Vendor/Miscellaneous Payment Enrollment Form |
Form |
| Appeals regarding Certification of Health Conditions |
Other-Document |
| Appeals Regarding Treatment |
Other-Document |
| Appeals regarding Eligibility Denial |
Other-Document |
| WTC Pentagon & Shanksville, PA Eligibility Application |
Form |
All Historical Document Collections
| Reference | Filing | Received | Concluded | Action |
|---|---|---|---|---|
| 201304-0920-001 | New collection (Request for a new OMB Control Number) | 2013-04-01 | Approved without change |