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PHYSICIANS CERTIFICATION OF MEDICAL NECESSITY UNDER THE ENERGY (Department of Labor)

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PHYSICIAN’S CERTIFICATION OF MEDICAL
NECESSITY UNDER THE ENERGY EMPLOYEES
OCCUPATIONAL ILLNESS COMPENSATION
PROGRAM ACT
U.S. Department of Labor
Office of Worker
s’ Compensation Programs
Division of Energy Employees Occupational
Illness Compensation
Instructions
Please provide the identifying information requested below, indicate the date of your
face-to-face physical examination of your patient, check either the box requesting an in-
home assessment or the other box indicating you are attaching a Letter of Medical
Necessity, sign and date the bottom of this form. For additional instructions, see page 2.
DO NOT WRITE IN SHADED AREAS.
OMB Control No: 1240-0002
Expiration Date: 03/31/2022
Patient Information
Name
(Last, First, Middle Initial)
Date of Birth:_______________
DEEOIC Case I.D. ____________________
SSN: XXX-XX-_______________
(Last Four Only)
Address(Street, Apt. #, P.O. Box)
Telephone Number(s)
Home: ( ) -
Other: ( ) -
(City, State, Zip Code)
Treating Physician Information
Physician Name (Last, First, Middle Initial)
Telephone Number(s):
Office: ( ) -
Other: ( ) -
Address (Name of Facility, Street, Suite #, P.O. Box)
(City, State, Zip Code)
Circle One: M.D. or D.O.
National Provider Identifier:
DEEOIC Accepted Conditions
Date of Physician’s Examination, and Request for Assessment or Letter of Medical Necessity (check appropriate
box)
Physical Examination:
In-home Assessment Requested
Before prescribing home health care, nursing home or assisted living services for my patient, I am
requesting an in-home assessment to assist me in determining the need for services related to
the DEEOIC accepted condition(s) listed above.
Letter of Medical Necessity Attached
I have attached a Letter of Medical Necessity that contains both a plan of care and the rationale
for my conclusion that the prescribed home health care, nursing home or assisted living services
are medically necessary for treatment of the DEEOIC accepted condition(s) listed above.
Physician Declaration
By signing this Form EE-17B, I acknowledge that: the above-named patient is currently under my care for the DEEOIC accepted
condition(s) listed above; I have personally examined this patient on the date indicated above; I have read the DEEOIC Home
Health Care Letter to Physicians; I understand that DEEOIC only pays for care that is medically necessary for treatment of
DEEOIC accepted conditions; and I understand that DEEOIC cannot pay for care for any condition that may be a consequence
of DEEOIC accepted condition(s) until specifically claimed for and accepted by DEEOIC. I have attached copies of the relevant
medical documentation and objective testing supporting my attached Letter of Medical Necessity (if I have provided one).
___________________________________________________________ ___________________
Physician Signature Date
Page 1
Form EE-17B
January 2015
Additional Instructions to Physician
Form EE-17B is used to obtain a Letter of Medical Necessity (LMN) from the treating physician that describes the claimant’s Home Health
Care (HHC) needs as they relate to one or more of the DEEOIC accepted conditions identified on this form. The LMN must state that you
have personally met with and examined your patient within the past 60 days, and have made a determination as to the type of care, and
the frequency and duration of such in-home care, as it relates to the accepted condition(s).
If you feel th
at you need more information from your patient before you can prepare the LMN, you may first wish to schedule a visit with
your patient to discuss his/her HHC needs. If you feel that an in-home assessment by a provider of HHC services would be of value,
please check the appropriate box on page 1, sign the Physician Certification at the bottom of the form and return it to the DEEOIC Central
Mail Room address below. Our claims staff will notify the HHC provider, designated by your patient, that an in-home assessment of HHC
needs has been authorized by DEEOIC. Once the assessment has been completed, our district office will forward a report to your office,
and you can proceed with preparing your LMN. Once you have the necessary information to prepare a LMN, here is the specific
information we are seeking:
Physical Examination: DEEOIC requires a physician to have personally visited with and conducted a physical examination of the
patient, within the past 60 days. Your LMN should provide a written narrative describing your physical findings at the time of
examination, and the specific functional limitations resulting exclusively from the accepted work-related illness.
Type and Duration of Care: The LMN must clearly specify the type(s) of HHC required, and for each type of care must specify the
number of hours per day, and number of days per week for that particular type of service. The letter must also provide a
description of the specific medical services to be performed by each type of caregiver. Examples of the various types of HHC
available are as follows:
Skilled N
ursing Care (RN/LPN)
Home Health Aid/Personal Care Attendant
Respiration Therapist
Occupational/Physical Therapist
Please be sure to sign the Form EE-17B and mail it to the claims examiner at:
U.S. Department of Labor OWCP/DEEOIC, P.O. Box 8306, London, KY 40742-8306.
Privacy Act Statement
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees
Occupational Illness Compensation Program Act (42 USC 7384 et seq.) (EEOICPA) is administered by the Office of Workers’ Compensation
Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate
families. (2) Information received will be used to determine eligibility for, and the amount of, benefits payable under EEOICPA, and may
be verified through computer matches or other appropriate means. (3) Information may be disclosed to physicians and other health
care providers for use in providing treatment, performing evaluations for the Office of Workers’ Compensation Programs, and for other
purposes related to the medical management of the claim. (4) Information may be given to Federal, state, and local agencies for law
enforcement purposes, to obtain information relevant to a decision under EEOICPA, to determine whether benefits are being paid
properly, including whether prohibited payments have been made, and, where appropriate, to pursue debt collection actions required or
permitted by the Debt Collection Act. (5) Failure to disclose all requested information may delay the processing of the claim or the
payment of benefits, or may result in an unfavorable decision.
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to the information collections on this form
unless it displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 30
minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and
completing and reviewing the collection of information. You are not required to respond to this collection, but failure to respond may
result in an unfavorable decision. Send comments regarding the burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Workers’ Compensation Programs, Room
S3524, 200 Constitution Avenue N.W., Washington, D.C. 20210, and reference OMB Control No. 1240-0002 and Form EE-17B. DO NOT
SUBMIT THE COMPLETED FORM TO THIS ADDRESS.
Page 2
Form EE-17B
January 2015
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PHYSICIANS CERTIFICATION OF MEDICAL NECESSITY UNDER THE ENERGY (Department of Labor)

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