EEOICPA BULLETIN NO.03-01

Issue Date: May 2, 2003

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Effective Date: May 2, 2003

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Expiration Date: May 3, 2004

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Subject: Medical Second Opinions

Background: The attending physician is the primary source of medical evidence in most cases, but sometimes his or her report does not meet the needs of the Office. When this happens, the Claims Examiner (CE) may request a medical second opinion. The District Medical Consultant (DMC) may recommend a medical second opinion examination, but the CE usually initiates these medical examinations.

Section 20 CFR Part 30.410 of the Final Rule states that "OWCP sometimes needs a second opinion from a medical specialist. The employee must submit to examination by a qualified physician as often and at such times and places as OWCP considers reasonably necessary. Also, OWCP may send a case file for second opinion where no actual examination is needed, or where the employee is deceased."

It is the policy of OWCP to ensure that medical second opinion examinations be of the highest quality possible and that the selection process for second opinion specialists be fair and well documented. Accordingly, it is desirable to provide policy guidance for the individuals involved in the process at the District Offices.

There are three key individuals involved in the process: the CE; the Medical Scheduler in each District Office, who is selected by the District Director; and the District Director or her/his designee, who oversees this process.

Reference: 20 CFR Part 30.410 and Section 10 of Chapter 2-300 of the EEOICP Procedure Manual Chapter 2-0300.10.

Purpose: To describe the process for requesting a medical second opinion examination.

Applicability: All staff.

Actions:

1. Roles and Responsibilities. The following individuals are responsible for the indicated actions.

Claims Staff. CEs are responsible for ensuring that all necessary information is sent to the Medical Scheduler to allow the medical second opinion to occur. The CE makes all required entries in ECMS for activities related to the medical second opinion. The CE is also responsible for advising the District Director or designee about problems with the quality or timeliness of medical reports, as well as any complaints received from claimants.

Medical Scheduler. This individual, designated by the District Director, is responsible for scheduling specific medical appointments. Only the Medical Scheduler selects physicians; claims staff does not have access to the Physicians Directory (PD) database.

District Director or designee. This individual is responsible for evaluating complaints about specific physicians and problems with the quality and timeliness of their reports.

2. When a CE determines that a second opinion is necessary, per instructions in PM Chapter 2-300.10, the CE prepares the case for referral. The CE must ensure that all medical second opinion examinations are scheduled through the Medical Scheduler.

The Medical Scheduler must make the appointment within a reasonable amount of time after initially requested by the CE. The claimant must be provided with 30 days prior notice of the scheduled appointment. The CE indicates any special period within which the examination is required. If the physician cannot see the patient within this period, another physician is selected, if possible.

3. The following information is prepared by the CE and given to the Medical Scheduler. Attachment 1 must be used to transmit the required information. The case file must be forwarded to the Medical Scheduler from the CE.

The CE completes all of the information required in Attachment 1 except for the section that provides the information on the second opinion physician. The Medical Scheduler completes this portion of the form. The section concerning required medical information, e.g., X-ray or CT scan films, lists information that the claimant must bring to the medical appointment (this medical information is requested in the letter to the claimant). The CE signs the form before forwarding it to the Medical Scheduler.

The Statement of Accepted Facts (SOAF) is a narrative summary of the factual findings in a case. The SOAF must include the claimant’s name and case file number; a detailed description of the claimant’s employment history; personal information, such as date of birth, date of death, etc.; exposure data, such as radiation, beryllium, silica; accepted condition(s); and any other diagnosed medical conditions. Additional medical information is contained in the case file, and need not be reiterated in the SOAF.

· The CE prepares a letter to the physician that lists the questions that he or she must specifically address (see Attachment 2 for a sample letter). The CE must limit the questions to only those that address the particular issue or problem for which clarification is required.

· For the information discussed above, one copy of each must be sent to the physician (except for Attachment 1) and one copy of each must be placed in the case file.

· The CE must be impartial if making a specific request to select or not select a certain physician.

4. When selecting a physician to conduct a second opinion, the Medical Scheduler ensures that an appropriate specialist is chosen. For example, if a second opinion is being arranged to examine a cancer patient, the most appropriate specialist is a medical oncologist. Physicians are selected from the Physicians Directory database to provide second opinion examinations.

In some instances, the Medical Scheduler may send a case file for second opinion review where actual examination is not needed, or where the employee is deceased.

5. The Medical Scheduler uses the Physicians Directory (PD) database to select a physician. The database can be accessed at http://www.boardcertifieddocs.com/abms/default.asp.

Enter the user ID and password (this information is available to each District Director). Click on "Advanced Search."

Enter the information for the location of the physician (zip code must be included). Sometimes, five digit zip code matching is too limited. In these instances, use the first three 3 numbers. For example, if 94105 is entered for the zip code and gets no matches, try 941**.

Use the "Certification" or "Sub-Certification" selections to designate a specialist. The Sub-Certification selection contains the specialties of most interest to the DOL program. For example, use "Internal Medicine" as the "Certification" when looking for medical oncologist or a pulmonologist as a "Sub-Certification."

After the search is completed, the Medical Scheduler contacts the specialists, starting with the first name on the list or, if the list of physicians was previously created (see next bullet item), use the next name on the list.

To allow for the rotation of specialists used for second opinions, the District Office must develop and maintain an internal tracking system (e.g., a spreadsheet) that will allow the Medical Scheduler to identify when a particular physician last provided a second opinion, and will also allow the Medical Scheduler to add contact information. If a physician subsequently indicates that he or she no longer wishes to be involved in the program, this information must be added to the system so the Medical Scheduler knows not to contact that physician.

For zip codes that have small numbers of available physicians, it may be necessary to use the same second opinion physician on a more regular basis. This is acceptable as long as the physician has not been involved with any medical examinations of the claimant. Also, in areas where there are limited numbers of qualified physicians available, the need for extended travel to see a physician will be addressed on a case by case basis.

The following guidance is intended to address possible problems that may arise in scheduling second opinion examinations.

The zip code used is normally that of the claimant’s home address. Other zip codes must not be used unless no physicians in the claimant’s zip code practice the necessary specialty. In this instance, the Medical Scheduler selects the closest neighboring zip code. Since zip codes are not always contiguous, it may be necessary to check a zip code map or internet site (e.g., http://www.usps.com/zip4/ or http://zip.langenberg.com/) to find the neighboring zip code. If necessary, the scheduler could ask the claimant what larger cities are located within 100 miles of his/her residence.

The claimant has requested an examination elsewhere. For instance, if the claimant is away from home temporarily, the zip code of the temporary location may be used.

 

The Medical Scheduler must try to arrange for the second opinion examination within a reasonable distance of the residence of the employee. Unless unusual circumstances exist, the examination must be scheduled with a physician within 100 miles of the employee's residence. A distance of 25 miles or less is preferable. If extended travel is required, the arrangements and reimbursement are handled on a case by case basis.

The Medical Scheduler contacts the physician directly by telephone and establishes the date and time of the examination. The Medical Scheduler may select any physician for the second opinion so long as he/she carries the appropriate specialty and is willing to accept the patient for evaluation. Use directory assistance or an internet search to get the physician’s phone number if it is not listed in the PD database.

Also, the Medical Scheduler should ensure that the physician is enrolled in our program. A DEEOIC provider number is required before the physician can be paid for his services. If the physician does not have a DEEOIC provider number, the Medical Scheduler must include a copy of the Provider Enrollment Form (Form OWCP-1168) and the complete provider package with the letter sent to the physician. After the completed form is returned, the Medical Scheduler forwards the completed form to the medical bill processing contractor, which provides the Medical Scheduler with a DEEOIC provider number for the physician.

The Medical Scheduler writes a cover letter to the physician that confirms the appointment and includes a description of the billing specifications (See Attachment 3). As noted in Attachment 3, the provider of any diagnostic testing, requested by the physician, must submit the bill directly to the district office. The Medical Scheduler must ensure that this provider is an enrolled provider (see #8 above for further details). The Medical Scheduler also creates the HCFA-1500 form for the diagnostic testing service by filling in the appropriate information, including entering the code V70.9 in section 21 and entering the code PE001 in section 24D.

10. After contacting the physician, the Medical Scheduler notifies the claimant in writing of the following (see Attachment 5 for a sample letter):

The name and address of the physician to whom he or she is being referred as well as the date and time of the appointment.

Any request to forward x-rays, electrocardiograms, etc., to the specialist.

A warning that adjudication of the claim may be suspended for failure to report for examination.

Copies of travel reimbursement forms (see PM Chapter 2-300 (15)).

After the examination has been arranged, the Medical Scheduler sends the following items to the physician and also place copies of these documents in the case file:

The cover letter to the physician that includes a description of the billing specifications (See Attachment 3).

The SOAF and questions prepared by the CE.

Copies of all medical reports from the case record.

A Form HCFA-1500. The Medical Scheduler finalizes the package by partially completing the HCFA-1500, completing the boxes for the claimant’s name, address, city, state, zip code, birth date, sex, and case file number (See Attachment 4). The Medical Scheduler also completes section 21 of this form by entering the code V70.9 and by entering the code PE001 in section 24D (these codes are to be used only when an actual exam is to be performed). There is no dollar limit on second opinion examinations. If only a review of medical information is needed, use V49.8 and FR001 in sections 21 and 24D, respectively. There is a $2,000 limit when only a review of the medical file is performed and this must be noted in the letter to the physician.

An express mail envelope and air bill in the package so that the physician may return the medical report and bill to the appropriate DO.

12. The Medical Scheduler forwards the entire case file to the CE after the package is sent to the second opinion physician. Upon receipt of the case from the Medical Scheduler, the CE must enter the code 2S into the Claims Status screen in ECMS. The status effective date is the date that the package is sent to the second opinion physician.

13. The CE must enter the following information into ECMS. Go to the Medical Condition screen and press Insert key to add a line. On the Employee Medical Condition screen, enter the appropriate "V" code, either V70.9 or V49.8, as appropriate, into the "ICD-9" field. Select "PA - Prior Approval" from the drop down choices in the "Condition Type" field. Enter in the "Status Effective Date" and "Eligibility End Date" fields the date of the scheduled examination. If no examination is scheduled, enter in these fields the same date associated with the status code 2S.

14. The Medical Scheduler must enter a call-up for the CE in the system for the date of the appointment. The CE follows up by calling the physician's office to see if the claimant came for the appointment. If the claimant failed to appear for the appointment, the CE must call the claimant to inquire why he/she did not keep the appointment. The CE then requests the Medical Scheduler to reschedule the appointment. If the claimant fails to keep the second appointment or refuses to attend an appointment, the CE sends a letter and enters ECMS status code DM into the case status screen with a status effective date being the date of the letter. The letter advises the claimant that no further adjudication of the outstanding issue may be undertaken until the claimant attends the scheduled appointment.

If the claimant keeps the appointment, the CE places a call-up for the Medical Scheduler in the system for 30 days from the date of the appointment. The Medical Scheduler is then responsible for follow-up with the physician’s office for receipt of the report.

If someone accompanying the employee to the examination disrupts or obstructs the examination in such a manner that the physician cannot provide OWCP with the desired medical second opinion (for example, the person prevents the physician from obtaining clinical data necessary for preparation of the opinion, or will not permit the physician to obtain a pertinent history from the employee), the CE arranges for scheduling of another medical second opinion examination with a different physician. In this situation, the CE must create a new or modified Medical Condition record in ECMS (see Action #13 above) depending on whether the first physician will be paid for partial services. In its referral letter for this second attempt, the CE must inform the employee that nobody will be permitted to accompany him/her due to the disruption of the prior examination. The ONLY exception to this flat ban will be if OWCP determines that "exceptional circumstances" exist. This is to be strictly limited to such things as permitting an interpreter for a deaf employee.

If the employee refuses to attend the second examination, or someone the employee brings disrupts the examination again, further action on the claim is suspended. The CE sends a letter and enters ECMS status code C2 into the case status screen with a status effective date being the date of the letter. The letter advises the claimant that no further adjudication of the outstanding issue may be undertaken until the employee submits to the directed examination.

If the claimant keeps the appointment, the CE places a call-up for the Medical Scheduler in the system for 30 days from the date of the appointment. The Medical Scheduler is then responsible for follow-up with the physician’s office for receipt of the report.

15. The second opinion physician submits his/her medical review and completed Form HCFA-1500 to the Medical Scheduler. The Medical Scheduler retains the original of the HCFA-1500 and a copy of the medical report and forwards a copy of the HCFA-1500 and the original medical report to the CE.

16. Once the CE receives the medical narrative from the second opinion specialist, the report must be reviewed to determine if it meets OWCP’s needs. The CE reviews the report for accuracy and completeness, ensuring that the report includes adequate discussion of the following: interpretation of test results and medical reports submitted for review; answers to each question posed; and the diagnosed medical condition(s).

The Medical Scheduler must be notified if a report is found to be deficient. This allows the Medical Scheduler to consider whether OWCP should continue to request second opinions from the physician. Also, it would allow the CE and Senior CE to see if this has been a problem with other reports from the physician.

17. If the report is found to be deficient, the CE prepares a letter to the physician requesting clarification of the initial report. The CE must advise the physician of the deficiencies in the initial report and request that the physician provide an addendum report that clarifies the deficiencies.

In preparing the request for clarification, the CE must include:

a letter to the physician describing the deficiencies and any questions to be answered;

copies of all the medical evidence; and

the SOAF.

18. If the report adequately addresses the CE questions, the CE enters code 2R into the Claims Status screen in ECMS. The status effective date is the date the report is date-stamped into the office. The CE must modify the Medical Condition record in ECMS by updating the status effective and eligibility end dates, as needed, to coincide with the date of service on the HCFA-1500. Also, the CE selects "A – Approved" from the "Condition Status" field.

In some situations, the findings or opinions of a second opinion specialist or a DMC may differ from those of the claimant's attending physician. If the CE determines that the weight of the medical evidence (see PM Chapter 2-300.5) rests with the report of the second opinion physician, then action can proceed in accordance with that physician's conclusion. If, however, the opposing reports are found to be of equal probative value, the CE will need to resolve the conflict. The CE first sends the second medical opinion specialist’s report to the claimant's attending physician to see if the physician agrees or disagrees with that report. If the claimant's attending physician disagrees, the case will be referred to a referee medical specialist. These referrals require the CE to create a new Medical Condition records in ECMS to facilitate payment (see Action #13 above). The CE then refers the case file to the Medical Scheduler.

19. When reviewing the bill, the Medical Scheduler must ensure that the:

Billing hours, charges, provider enrollment number, and case reviews are appropriate;

Claimant’s name and SSN are correct;

Federal tax ID number is correct;

Date of service is correct; and

Bill is signed by the specialist and includes his/her name and address.

Provider number is entered in item 33.

The Medical Scheduler must never make any other marks or changes to the bill. Deficient bills must be returned to the physician.

20. If all required billing information is included, and the CE entered all appropriate codes into ECMS, the Medical Scheduler approves the bill by writing "APPROVED" in the top right hand corner along with his/her signature, district office location, and date. The writing must not be placed over any relevant bill information. All writing must be in black ink only, no red ink. See Attachment 6 for an example of a completed HCFA-1500 form.

21. #9; The CE must forward the copy of the narrative report along with the approved HCFA-1500 to DEEOIC’s medical bill processing contractor at:

Energy Employees Occupational Illness Compensation Program

P.O. Box 727

Lanham-Seabrook, MD 20710-0727

22. The Medical Scheduler maintains a file that includes individual folders labeled with the names of the physicians. The Medical Scheduler places a copy of all completed medical reviews in the respective folder.

23. If the CE receives a request from the claimant for a copy of the second opinion specialist’s report, the CE must attach a cover letter to the copied report which includes a disclaimer paragraph. For example, "Attached is a copy of the medical report that you requested. Please be advised that {Enter the physician’s name} is a medical consultant for the Department of Labor. The Department of Labor made the final decision in this claim. Please do not contact {Enter the physician’s name} regarding this report. If you have additional evidence to submit in support of your claim or if you have any questions or concerns regarding this report, please contact me on {Enter CE’s contact number}."

24. The Medical Scheduler informs the District Director or designee of any unreasonably late reports, e.g., later than 60 days after the examination.

25. Any complaints regarding these matters must be made in writing. If the claimant complains about the conduct of the physician during the examination, the CE forwards the complaint and copies of the report, the SOAF and the questions to the physician, to the senior or supervisory CE for forwarding to the District Director or designee. The District Director or designee reviews the complaint and acts accordingly.

26. With the use of the PD database, the District Director or designee needs to be scrupulous about ensuring that the database is used appropriately. While the number of medical second opinion examinations may be small, there are still a few issues that need to be addressed.

Based on the quality of his or her medical report, a physician may be removed from the pool of physicians for future examinations at the recommendation of the Medical Scheduler. The District Director or designee reviews the documentation forwarded by the Medical Scheduler and decides whether continued use of the physician is appropriate. The District Director or designee then informs the Medical Scheduler of his or her decision so the tracking system can be updated, as appropriate.

Based on the timeliness of the medical report, a physician may also be removed from the pool of physicians to be considered for future examinations. The District Director or designee reviews the documentation forwarded by the senior or supervisory CE from the CE, decides whether removal is appropriate and informs the Medical Scheduler of this decision.

For example, if a physician provides a report one month late on a complex case, the District Director or designee may choose to take no action. On the other hand, if a physician takes several months to provide a report after many calls from the CE, or provides no report at all, the District Director or designee will direct the Medical Scheduler to annotate the tracking system to reflect the physician’s removal from the pool of future referrals and include the specifics of the incident. No minimum number of complaints needs to be lodged before a physician can be removed from the pool. One complaint, if severe enough, may be sufficient.

The District Director or designee is responsible for reviewing all reports of complaints from employees and for taking appropriate actions.

If a physician has performed multiple examinations before without reported problems, and the complaint does not appear to be supported by the evidence in the case file, the District Director or designee may choose not to act on the complaint.

By contrast, if another complaint has recently been lodged against the physician, and both complaints have been supported by the case files in question, the District Director or designee may consider removing the physician from the pool of further reviews.

27. Any physician who expresses an interest in being added to the PD database, or who is identified by a staff member, is to be referred to the District Director or designee. The physician is told to contact the publisher of the PD database to be considered for addition to their directory

(BoardCertifiedDocs, Phone: (800) 401-9962 or at mdc.customerservice@elsevier.com).

Disposition: Retain until incorporated in the Federal (EEOICPA) Procedure Manual

PETER M. TURCIC

Director, Division of Energy Employees

Occupational Illness Compensation

 

Attachments

Distribution List No. 1: Claims Examiners, Supervisory Claims Examiners, Technical Assistants, Customer Service Representatives, Fiscal Officers, FAB District Managers, Operation Chiefs, Hearing Representatives, District Office Mail & File Sections

Information for Medical Second Opinion

Employee’s Name

Case No.

Two (2) copies of a STATEMENT OF ACCEPTED FACTS and QUESTIONS TO THE SECOND OPINION PHYSICIAN are attached. One copy of each should be mailed to the second opinion physician and one copy retained in the claimant’s file.

The following physicians have been involved with this case.

1.

6.

2.

7.

3.

8.

4.

9.

5.

10.

Type of Specialist Requested:

Examination of employee required?

□ Yes □ No

 

Name and address of specialist

Furnish the following X-rays, etc. (list items and give source and date)

 

 

Comments:

 

Provide specialist with:

□ Copies of medical reports □ Other (Specify)

□ Entire case file ________________________________________

Signature

 

   

Questions for Second Opinion Physician

MEMO TO: MEDICAL SECOND OPINION SPECIALIST

RE: {Claimant’s Name}

FILE: XXX-XX-XXXX

Thank you for taking the time to examine our claimant. The purpose of your examination is to assess the patient’s medical condition with respect to the stated condition(s) in the claim.

Once you have reviewed the enclosures, please conduct a physical exam of the claimant. In a separate medical narrative please list a history of the employee’s injury, physical findings on exam, diagnostic test results, and a diagnosis. IN ADDITION, YOU MUST PROVIDE AN UNEQUIVOCAL RESPONSE TO THE FOLLOWING QUESTIONS:

Based on your physical examination of the claimant, and review of the records, are the findings consistent with a diagnosis of __________? NOTE: Use a separate item number for each medical condition that is addressed.

Please respond YES or NO and provide the rational which justifies your conclusion.

Letter to Physician

 

U. S. DEPARTMENT OF LABOR EMPLOYMENT STANDARDS ADMINISTRATION

OFFICE OF WORKERS’ COMPENSATION PROGRAMS

DIVISION OF ENERGY EMPLOYEES’ OCCUPATIONAL

ILLNESS COMPENSATION

200 CONSTITUTION AVE

ROOM C-4511

WASHINGTON DC 20210

TELEPHONE: (202) 693-0081

 

{Date}

File Number: XXX-XX-XXXX

Employee: {Name}

{Name and Address}

Dear Dr. _____:

Arrangements have been made with your office for the above named claimant to undergo an independent medical assessment on {Date} at {Time}.

The purpose of the examination is to assess this employee’s medical condition with respect to the stated condition(s) in the claim. Enclosed is a copy of the pertinent medical evidence from the case file; a Statement of Accepted Facts, which presents a broad history of the case; and a list of questions to be addressed. You are advised to review this information prior to the examination to garner an understanding of the case context.

[NOTE: This sentence can be used if required - The patient has been instructed to bring with them {Identify specific medical information}. However, you are authorized to refer the employee for any non-invasive diagnostic testing which you feel is required to address the questions raised by the District Office. The provider of such services must submit billing directly to the address listed above for payment. The above listed case file number must appear on any billing submitted.

You are ensured payment by the Office of Workers’ Compensation Program (OWCP) for services rendered. Enclosed in this package is a Form HCFA-1500 with appropriate authorization codes. This form must be used to bill for your service. If you have any difficulties completing the form, please contact me. Please be aware that payment cannot be processed until a report is received which addresses the particular questions being raised.

Please note that you must not release your report to the claimant or representative, but should instead refer any request for it to the Department of Labor Claims Examiner.

Also, please note that the rescheduling of an examination cannot be done without the authorization of the DOL’s District Office.

If there are any questions or concerns, please contact me directly at the District Office at XXX-XXX-XXXX. You may fax the report with the completed billing form attached to XXX-XXX-XXXX.

Sincerely,

 

{Medical Scheduler’s name and title}

Attachment 4, Form HCFA-1500 (Partially Completed)

 

 

Letter to Claimant

 

U. S. DEPARTMENT OF LABOR EMPLOYMENT STANDARDS ADMINISTRATION

OFFICE OF WORKERS’ COMPENSATION PROGRAMS

DIVISION OF ENERGY EMPLOYEES’ OCCUPATIONAL

ILLNESS COMPENSATION

200 CONSTITUTION AVE

ROOM C-4511

WASHINGTON DC 20210

TELEPHONE: (202) 693-0081

 

{Date}

File Number: XXX-XX-XXXX

{Name and Address}

Dear Mr/s. _______:

This letter is in reference to your EEOICPA claim.

We have arranged for you to undergo an evaluation with {Dr. ______} on {Date} at {Time}. This examination is designated as a medical second opinion assessment. The purpose of the examination is to assess your medical condition(s) with respect to your claim for benefits.

The address for the physician is as follows:

{________, MD

Address

Phone Number}

Upon receipt of this letter, please phone the physician’s office to confirm the appointment and to obtain any special instructions pertaining to the examination.

The Division of Energy Employees Occupational Illness Compensation is covering the cost of the examination and any non-invasive diagnostic testing required by the doctor.

You are responsible for obtaining and taking with you {state any medical information required to be brought to the examination, e.g., X-ray or CT scan films}. In addition, if the selected doctor requires you to undergo diagnostic testing at a separate facility, you are required to make arrangements to have the tests completed. Failure to undergo testing when instructed by the selected doctor may result in the suspension of further adjudication of your claim.

Please be aware, you are required to attend the examination as scheduled by the District Office. You are not permitted to reschedule the examination unless you obtain authorization from the District Office. If you will be unable to attend the examination as scheduled, please contact the District Office. Further adjudication of your claim may be suspended as a result of obstruction or refusal of examination scheduled by the District Office. This suspension will continue until you cooperate completely with the instructions pertaining to the examination. Accordingly, you must attend the examination and adhere to instructions in regards to obtaining any necessary diagnostic tests.

We have attached a Medical Travel Refund Request (OWCP - Form 957. You may claim any reasonable and necessary expense incurred in obtaining the required examination. Please see the instructions on the Form 957 for further information on how to claim reimbursement. It is your responsibility to make the necessary arrangements to attend the examination.

If you have any questions or concerns, please contact me at the District Office at XXX-XXX-XXXX or fax XXX-XXX-XXXX.

Sincerely,

 

{Medical Scheduler’s Name and Title}

Attachment 6, Form HCFA-1500 (Completed)