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 3830 958 17427 Form n/a
Decertification Letter and Appeal Notification for a Health Condition Removed 0 0 0 Form and Instruction n/a
Designated Representative Modified 1300 325 5915 Form and Instruction n/a
Designated Representative Revocation Form New 15 4 0 Form and Instruction 0920-0891
Disenrollment and Appeal Process for Responders Removed 0 0 0 Form and Instruction n/a
FDNY Responder Eligibility Application Modified 140 70 1701 Form and Instruction n/a
Form n/a
General Responder Eligibility Application Modified 6215 3108 56557 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
HIPAA Authorization to Release Information Modified 1300 325 5915 Form and Instruction n/a
Member Satisfaction Survey New 6600 3300 0 Form and Instruction 0920-0891
Pentagon / Shanksville Responder Modified 242 121 2202 Form and Instruction n/a
Petition for the Addition of a Health Condition (previously approved under 0920-0929) Modified 35 35 1260 Form and Instruction n/a
Pharmacy - Outpatient Prescription Pharmaceuticals Removed 0 0 0 Other-Dummy Form Representing an Electronic Data Transfer
Reimbursement Denial Letter and Appeal Notification - Providers Removed 0 0 0 Form and Instruction n/a
Request for Certification of Health Condition (WTC-3) Removed 0 0 0 Form and Instruction n/a
Responder Denial Ltter and Appeal Notification - Treatment Removed 0 0 0 Form and Instruction n/a
Responder Denial and Appeal - Eligibility Removed 0 0 0 Form and Instruction n/a
Responder Denial and Appeal - Health Conditions Removed 0 0 0 Form and Instruction n/a
Responder Medical Travel Refund Request Removed 0 0 0 Form and Instruction n/a
Survivor Eligibility Application Modified 9240 4620 55440 Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
Form and Instruction n/a
WTC Health Program General HIPAA Authorization to Third Parties New 30 8 0 Form and Instruction 0920-0891
WTC Health Program HIPAA Authorization for Deceased Individuals New 30 8 0 Form and Instruction 0920-0891
Total burden requested under this ICR: 28977 12882 146417  
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