0920-0891 WTCHP Designated Representative HIPAA Authorization_10FE

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

HIPAA Authorization for Designated Representatives
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 appoint a
Designated Representative (such as with the WTC Health Program Designated Representative Appointment Form),
you must also submit this form regarding the individual you are appointing as your Designated Representative. This
form must be filled out in its entirety by the WTC Health Program applicant or member.1
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.
I,

, give permission to the U.S.
(Name of Applicant or Member)
Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), National Institute for
Occupational Safety and Health (NIOSH), World Trade Center (WTC) Health Program, including federally-funded
contractors acting on behalf of and funded by the WTC Health Program, to use and/or disclose my protected health
information, as described below, to

for the purposes of him/her
(Name of Designated Representative)
acting on my behalf and representing my interests in the WTC Health Program, as permitted in 42 C.F.R. pt. 88.
Information to be disclosed to my Designated Representative may include any and all information relevant to the
Designated Representative representing my interests in the WTC Health Program, including protected health
information contained in medical, treatment, and diagnostic records as necessary.
I wish to exclude the following information from such authorized disclosures to my Designated Representative
(describe):
This authorization expires
on the following date or event:
at the expiration of the WTC Health Program21
or at such time as I exercise my right to revoke this authorization in writing, whichever happens earlier. I may revoke
this authorization in writing at any time by sending written notification to the address listed above. Use or disclosure
of my protected health information by the WTC Health Program made prior to the Program’s receipt of my written
request to revoke this authorization will be governed by this authorization to the extent that the Program has taken
any action in reliance on this authorization already.
Signing this authorization is voluntary. The WTC Health Program may not condition treatment, payment, enrollment,
or eligibility for benefits on my signing this authorization. The information governed by this authorization may
be subject to further disclosure by the authorized recipient(s); such additional disclosures by third parties are
not subject to, nor protected by, this authorization. The WTC Health Program will give me a copy of this signed
authorization, upon request. (Requests may be made in writing to the above address.)
1 If the signatory is not the applicant or member, please include documentation demonstrating the signatory’s legal authority to act on behalf of
the applicant/member for HIPAA-authorized purposes.
2 The expiration of the WTC Health Program is defined as when the Program is no longer funded and is unable to provide services under Title
XXXIII of the Public Health Service Act, currently 2090.
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).

HIPAA Authorization for Designated Representatives

Printed Name of Applicant/Member

Date of Birth

Address

WTC Health Program ID (911#), if known

Address Line 2

Phone

Applicant/Member Signature

Date