WTC Health Program Records Request

General HIPAA Authorization for Disclosures to Third Parties [PDF, 3 pages, 156 KB]

The World Trade (WTC) Center Health Program maintains records about your care, including some medical records for treatments and services received through the Program, whether at a Clinical Center of Excellence (CCE) or through the Nationwide Provider Network (NPN). As a member, you can request these records using the form above at any time. You can also authorize the WTC Health Program to disclose your records to third parties by submitting the same form. These Program records may include, but are not limited to:

• Application materials;
• Program enrollment decision letters;
• Program certification decision letters, including denial decision letters;
• Available medical records, including treatment and diagnostic records.
  • Medical record requests will be forwarded to the CCE or NPN for fulfillment and only pertain to Program specific medical records.

Request Program Records for Deceased Members

HIPAA Authorization for Disclosures Regarding Deceased Individuals [PDF, 3 pages, 175 KB]

If you are a personal representative of a World Trade Center Health Program member who is deceased, you may be able to request their Program records or authorize the Program to send the records to a third party. To request a deceased member’s records, you will need to complete the form above and provide

• Proof of your legal authority to act on behalf of the deceased member,
• Proof of your identity as the personal representative, and
• Proof of the recipient’s identify if you are requesting these records to be sent to a third party.

The Program will evaluate these records requests after the form and all documentation are received.