U. S. DEPARTMENT OF LABOR 

EMPLOYMENT STANDARDS ADMINISTRATION                 

                OFFICE OF WORKERS’ COMPENSATION PROGRAMS

                DIVISION OF ENERGY EMPLOYEES’ OCCUPATIONAL ILLNESS COMPENSATION

                200 CONSTITUTION AVE, NW

                ROOM C-3321

                                                    WASHINGTON DC  20210

                    TELEPHONE:  (202) 693-0081

 

 

(Date)

                                 

(Medical Provider)

(Address)

 

 

RE:  {Employee’s Name}

 

Dear Medical Provider;

 

The Department of Labor, Division of Energy Employees Occupational Illness Compensation (DEEOIC), has received a claim from {Employee’s Name}, and has determined that {Employee’s Name} is eligible for an impairment evaluation in relation to the covered illness of {insert name and ICD9 of covered illness}.

 

{Employee’s Name} has identified you as his/her choice to perform an impairment evaluation in relation his/her covered illness of {insert name and ICD9 of covered illness}.  The DEEOIC will cover the cost of {Employee’s Name} impairment evaluation as long as the condition has reached a point where further improvement is not expected (Maximum Medical Improvement/MMI), or the employee is considered to be in the terminal stages of the illness. The evaluation must also be performed within one year of the date DEEOIC received the report, and not performed prior to the date (Filing Date) he/she filed for benefits under the EEOICPA.  The evaluation must be performed in accordance with the most current edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA’s Guides), with specific page and table references included in your report.  The physician must hold a valid medical license and Board certification/eligibility in an appropriate field of expertise.  The physician must also meet at least one of the following criteria: American Board of Independent Medical Examiners (ABIME) and/or American Academy of Disability Evaluating Physicians (AADEP) certification; and/or possess the requisite professional experience and medical work background in interpreting the AMA’s Guides to provide such ratings.  In order to show the requisite experience and background, please submit a written certification identifying your specific expertise and knowledge of the AMA’s Guides (i.e. years performing ratings, entities for which ratings were performed, experience in rating the given condition/body part).  

 

Please note that in agreeing to perform the impairment rating evaluation, you are stating and certifying that no more than 25% of your income in any of the five previous years has come from serving as a salaried employee, consultant or expert witness for employers, insurers, unions, claimant organizations or their counsel in litigation related to the Energy Employees Occupational Illness Compensation Program or similar state compensation programs. 

 

Payment for the impairment evaluation and required diagnostic tests are covered by the DEEOIC.  To bill the Department of Labor directly, please complete and return the enclosed EEOICP Provider Enrollment Form (OWCP-1168) and the OWCP-1500, to the district office in the enclosed self addressed envelope.

 

If you have any questions regarding this letter or impairment ratings in general, please contact the district office {1-800#}.

 

Sincerely,

 

 

Claims Examiner

 

Enclosure: 

 

Required Medical Evidence for Determining

Impairment Rating By Specific ICD-9 Codes

Provider Enrollment Package

OWCP-1500