MEMORANDUM FOR:   (check one)

 

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FROM:                                   CSC Bill Payer

           

SUBJECT:                              Payment of Service for a Metastasized Cancer

 

EMPLOYEE:____________________________ FILE NUMBER_______---______---________

 

In accordance with our established procedures, on __________ (date), the bill payer has paid for medical services related to the following metastasized cancer(s) listed below.  Please update ECMS and inform beneficiary of accepted condition.

 

                      Primary/Accepted

Metastatic Cancer (s)                  ICD-9 Code                  Diagnosis Date (if known)                        Cancer (ICD9 code)    

 

1.

 

 

2.

 

 

3.

 

The following medical reports and/or resources were used to make this determination (see attachments): Check each that are appropriate.

 

[  ] Medical report or bill ___________________________, dated: __________________

(report or bill is attached)

 

[  ] WEB MD Internet Site

 

[  ] OWCP Medical Director

 

[  ] Merck Manual

 

[  ] Staff Nurse

 

[  ] NIOSH Primary/Secondary Cancer Tables

 

[  ] CPT/ICD-9 Utility Table provided by OWCP Medical Director

 

[  ] Other (describe):

 

Number of documents attached: _________

 

___________________________                              ______________________

Signature of CSC Bill Payer                                          Date