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)
File Number:
Employee:
(Employee Name)
(Address)
Dear (Employee Name):
The district office of the Division of Energy Employees Occupational Illness Compensation (DEEOIC), has received your claim for medical benefits and compensation in relation to the covered condition of {insert name of covered illness(es)}. As a covered employee under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), you may also be eligible for compensation for any whole body impairment resulting from your covered illness(es).
Whole body impairment is a percentage rating that represents the extent of impairment of a person based on the organ(s) and or system(s) affected by the covered illness(es). An impairment rating may be performed once the condition has reached maximum medical improvement (MMI), and is unlikely to improve with additional treatment.
If you believe that you are eligible for an impairment rating, you have two options:
1. You may select a qualified physician to perform an impairment evaluation.
2. The DEEOIC can arrange for a qualified physician to perform an impairment evaluation.
To initiate your claim for impairment in relation to your covered illness(es), please respond in writing to the address listed above to inform the Department of Labor of your intent to pursue a claim for impairment.
If you select option one above, please provide the name, address, and telephone number of the physician you have selected to perform your impairment evaluation, so that the DEEOIC may contact your physician to provide the requirements for performing your evaluation.
The DEEOIC will cover the cost associated with obtaining an impairment evaluation, but please be advised in order for the DEEOIC to accept and pay for one evaluation by the physician or physician group of your choosing, the evaluation must be performed within one year of the date DEEOIC receives the report, and not performed prior to your filing date (Filing Date). The evaluation must be performed in accordance with the Fifth edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA’s Guides). 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, the physician must submit a written certification identifying his/her 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).
If you have any questions regarding this letter or impairment ratings in general, please call me toll-free at_____________.
Sincerely,
Claims Examiner
Enclosures