[Initial Medical Development Letter]
Claimant Name (or auth rep)†††††††††††††††††††††††††††††††††††††††††††††††† File Number
Street Address†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Accepted Conditions††
City, State, ZIP
Dear Claimant: (Insert Name of Claimant or Authorized Representative)
I am writing to you concerning your benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).† We have received a request to provide you with in-home medical care.† In order to properly evaluate and respond to this request, we need additional medical evidence.
Please have your treating physician prepare a written narrative report, providing our office with detailed information describing findings upon physical examination, your medical needs, the specific level of in-home nursing care required, the time period for which services are requested and a description of the specific services that the home health care provider is expected to provide. Additionally, the physician should provide medical rationale for the recommended care, relating the requested services to the accepted medical condition(s) listed above.
The following is an example of a narrative describing the type of care required: For the medical condition of (fill in the blank), the patient requires the care of an† RN or LPN,† three times weekly to administer and/or monitor medications and medical equipment, and to assist in respiration therapy for the next 3 months. The patient also requires the daily services of a home health aide during waking hours (total of 16 hours per day) to assist in ambulating, dressing, bathing and trips to the toilet.† This service is required for the next 3 months, at which time the patientís physical condition will be reevaluated. ††
By copy of this letter, your physician is requested to contact this office immediately if there are any problems with our request. If you (or your physician) already have the name of an in-home medical services provider you wish to have perform the initial assessment, please provide me with that information.
In the interest of expediting the request for care, by copy of this letter your physician is requested to please fax and mail a response to my office within 30 days, or contact me sooner if there are questions regarding this request.
If for any reason you are not requesting in-home health care, please advise me immediately in writing.
Thank you for your assistance.† Please contact me at the number listed below if you have additional questions or concerns.
(Insert POC CE Name and Signature)
Insert POC CE telephone & fax numbers
Cc:† (Physicianís name and address)