Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Clinic Selection Postcard for new general responders in NY/NJ to select a clinic Modified 2475 619 11261 Form n/a
Decertification Letter and Appeal Notification for a Health Condition New 5 8 135 Form and Instruction n/a
Designated Representative Modified 30 8 137 Form and Instruction n/a
Disenrollment and Appeal Process for Responders New 3 2 27 Form and Instruction n/a
FDNY Responder Eligibility Application Modified 45 23 547 Form and Instruction n/a
Form n/a
General Responder Eligibility Application Modified 2475 1238 22523 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
HIPAA Authorization to Release Information New 30 8 137 Form and Instruction n/a
Pentagon / Shanksville Responder Modified 630 315 5733 Form and Instruction n/a
Petition for the Addition of a Health Condition (previously approved under 0920-0929) New 60 60 2160 Form and Instruction n/a
Pharmacy - Outpatient Prescription Pharmaceuticals Modified 39150 653 9200 Other-Dummy Form Representing an Electronic Data Transfer
Reimbursement Denial Letter and Appeal Notification - Providers New 600 300 30000 Form and Instruction n/a
Request for Certification of Health Condition (WTC-3) Modified 20000 10000 1000000 Form and Instruction n/a
Responder Denial Ltter and Appeal Notification - Treatment Modified 26 39 702 Form and Instruction n/a
Responder Denial and Appeal - Eligibility Modified 45 23 405 Form and Instruction n/a
Responder Denial and Appeal - Health Conditions Modified 60 90 1620 Form and Instruction n/a
Responder Medical Travel Refund Request Modified 10 2 25 Form and Instruction n/a
Survivor Eligibility Application Modified 1350 675 8100 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
Total burden requested under this ICR: 66994 14063 1092712  
To view an IC, click on IC Title