Designated Representative in the WTC Health Program

What is a designated representative in the WTC Health Program?

A designated representative is someone whom you appoint and authorize to act on your behalf and represent your administrative interests in the WTC Health Program.

A designated representative is allowed to provide and obtain personal information regarding your application to the WTC Health Program, your benefits, and your membership in the Program. A designated representative can also make a request or give direction to the Program regarding your eligibility, certification, or any other administrative issue under the WTC Health Program, including appeals.

By designating a representative, you are authorizing the WTC Health Program to disclose your information to the individual and authorizing that individual to do the following:

• Serve as your representative in all matters pertaining to your membership in the WTC Health Program; and
• Receive and/or provide information pertaining to your membership and participation in the WTC Health Program, including copies of factual and medical evidence contained in your records for the Program. Please note: Any requirement of the WTC Health Program to notify you in writing is fully satisfied if sent to the designated representative

However, this person may not make medical care (e.g., treatment) decisions on your behalf.

Please note: The WTC Health Program does not generally accept Powers of Attorney for administrative matters. This includes signing and/or submitting an application on an individual’s behalf, signing Designated Representative forms on an individual’s behalf, and otherwise interacting with the WTC Health Program on an individual’s behalf.

Who can be a designated representative?

A designated representative in the WTC Health Program can be an individual such as an attorney, family member, advocate, or friend, unless that individual's service as a representative would violate any applicable provision of law. A parent or guardian may act on behalf of a minor. A Federal employee may act as a representative only on behalf of the individuals specified in, and in the manner permitted by, 18 U.S.C. §§ 203 and 205¹.

A designated representative differs from any attorney or licensed representative involved in any workers’ compensation or other worker-related injury or illness claim you may have. A designated representative can not be a group or an entity, one individual must be listed on the designated representative request.

What do I do if I already have a healthcare proxy or have assigned healthcare power of attorney?

You may have appointed a healthcare proxy or assigned a healthcare power of attorney to a family member or other person so that they may obtain, use, and disclose your personal information, and/or make medical treatment decisions on your behalf.

A designated representative in the WTC Health Program may not make medical care (e.g., treatment) decisions on your behalf. If you would like your healthcare proxy or person with healthcare power of attorney to also serve as your WTC Health Program designated representative, please complete and submit the required forms available below.

How many designated representatives can I appoint?

The WTC Health Program will only recognize one designated representative at a given time, and the designated representative must be properly appointed in writing using the forms below. If you would like to revoke the authority of your current designated representative, or appoint a new one, the process can begin with the revocation form below.

An entire organization or group of people—such as a law firm or multiple family members—is not permitted.

Once your designated representative has been properly appointed, the WTC Health Program will not recognize another individual as a designated representative until the appointment of the first designated representative is revoked in writing.

Please note: Your Clinical Center of Excellence or the Nationwide Provider Network may have additional requirements and forms for medical records to be released to your designated representative.

How do I appoint or change a designated representative?

To designate a representative, you must fill out and submit the Designated Representative and HIPAA Authorization forms 1 and 2 below to the WTC Health Program. To revoke and change your current designated representative, complete forms 1 and 2 with the new Designated Representative information and the Designated Representative Revocation Form (3) below. All forms must be fully completed and contain an actual signature. The WTC Health Program does not accept electronic signatures.

1. WTC Health Program Designated Representative Form (PDF, 2 pages, 96 KB)
2. HIPAA² Authorization for Designated Representative (PDF, 2 pages, 87 KB)
3. Designated Representative Revocation Form (PDF, 1 page, 53 KB)



Complete, print, and sign forms and submit by postal mail or fax to:

WTC Health Program
P.O. Box 7000
Rensselaer, NY 12144


Fax: 1 (404) 448-4485 or toll-free 1 (877) 646-5308

What if I need help or have additional questions about designated representatives?

If you need help or have additional questions, please call the WTC Health Program Help Line at 1-888-982-4748.

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1. An employee may represent, with or without compensation, the following: the employee (self-representation); a parent, spouse or child of the employee; or a person or estate that the employee serves as a guardian, executor, administrator, trustee or personal fiduciary. See Compensation to Members of Congress, officers, others in matters affecting the Government .


2. Health Insurance Portability and Accountability Act of 1996 (HIPAA). Learn more about HIPAA and the HIPAA Privacy Rule at https://www.hhs.gov/hipaa/index.html

Notice: The WTC Health Program will closely monitor any fraudulent activity including the submission of fraudulent information in support of a claim of eligibility or for necessary and covered services, fraudulent misuse of the WTC Health Program by health care providers participating in the program, and submission of claims for services not provided or needed as claimed. The WTC Health Program will report fraudulent conduct to federal law enforcement agencies and violators may be subject to criminal, civil, or administrative penalties. Information concerning suspected fraud related to the WTC Health Program by contractors, grantees, health care providers, or individual recipients should be reported to the Department of Health and Human Services Office of Inspector General by phone at 1(800)HHS-TIPS 1(800)447-8477; online at https://forms.oig.hhs.gov/hotlineoperations/index.aspx or in writing to the following address: U.S. Department of Health and Human Services, Office of Inspector General, ATTN: OIG HOTLINE OPERATIONS, P.O. Box 23489, Washington, DC 20026.