U.S. Department of Labor

Employment Standards Administration Office Of Workers’ Compensation Programs Division of Energy Employees’ Compensation Phone:       or       Fax:

Date:                                                      File Number: 

Response requested

Name

Address

Address

Dear Ms./Mr. :

I am writing in reference to your claim under Part E of the Energy Employees Occupational Illness Compensation Program.  Your claim has been accepted for medical benefits for the following covered illness(es):  List illness(es) and ICD-9 code(s).  Therefore, you may now be eligible for an impairment award due to your covered illness(es).

Use this paragraph if Beryllium Sensitivity or Pleural Plaques is accepted or accepted along with another condition

Your claim for [beryllium sensitivity or pleural plaques] has been recommended for acceptance.  This condition is not generally recognized to cause a decrease in lung function as is necessary for a compensable impairment rating.  However, if you have medical evidence documenting decreased lung function which is at least partially attributable to your [beryllium sensitivity or pleural plaques] and intend to pursue an impairment claim, you must respond in writing to the address listed above and state your intention to pursue a claim for impairment and provide the supporting medical documentation.  The medical evidence must specifically address how it is determined that the accepted condition is a contributing factor in the decreased lung function.

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).  You may be entitled to $2,500.00 for every impairment percentage point  that is the result of your 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.

To begin the impairment process, you must notify us in writing that you wish to claim impairment and for what illness(es) you are claiming impairment.  Please complete the attached form to indicate your preference.  If you elect to claim impairment, we will forward your medical records to a District Medical Consultant (DMC) for review.  The DMC is an independent contractor physician that is neither affiliated with the Department of Labor nor the Department of Energy.  Upon completion of the DMC’s review, he/she will provide an impairment rating.

You will not be physically evaluated by the DMC; therefore, we are requesting that you provide your current (within the last 12 months or most recent) medical records for your accepted illness(es).  Specifically, we request that you provide the following:

1) What we need from you:

List only the medical evidence required for the accepted condition(s) per “Required Medical Evidence for Determining Impairment Ratings by Specific ICD-9 Codes” (See Exhibit 4) that is NOT in the case file.  Also note that the attached ADL (Activities of Daily Living) Questionnaire should be completed by the employee’s treating physician.  (NOTE:  If the accepted illness is skin cancer or breast cancer, the supplemental ADL sheet for that condition should be included with the general ADL sheet.)

2) Other Information:

Use this section if some medical is older than 12 months.  Otherwise, do not use this section.

In addition, the following medical evidence required for the impairment evaluation has already been submitted to us; however, this evidence is more than 12 months old:

List medical evidence older than 12 months found in the case file and that is on the “Required Medical Evidence for Determining Impairment Ratings by Specific ICD-9 Codes”  and identify the date of each report.

You should be aware that older evidence may not reflect your current level of impairment since it is more than 12 months old.  We will be able to proceed with the impairment evaluation when you provide the requested medical evidence that we do not have (#1 above).  However, without current medical records, we may be unable to determine the present extent of your impairment.  Please be advised that an impairment evaluation for your covered illness(es) is authorized every 2 years.

If you wish to have your treating physician perform your impairment evaluation, please indicate such on the attached impairment benefits response sheet and provide the name and address of your physician by DATE (30 days from date of letter).  We will then attempt to contact your treating physician to determine if he/she possesses the required credentials to perform your impairment evaluation.  If we do not hear from you within 30 days or if your treating physician is not qualified to perform your impairment evaluation, we will proceed by forwarding your medical records to the DMC for review.

If you elect not to pursue an impairment claim at this time, we request that you complete the attached response sheet and return it to our office at the above address or fax it to us at .  Upon receipt of this notification, we will not undertake further development for impairment.  Should you wish to pursue a claim in the future, please notify us in writing at the address above.

We would like you to receive all the benefits to which you may be entitled and hope you will consider this very carefully; therefore, we would appreciate your response by DATE (30 days from date of letter).  If you have any questions regarding this letter or an impairment rating in general, please do not hesitate to call me, toll-free, at

( ) . 

Sincerely,

Claims Examiner

Enc:  Pamphlet, “How Do I qualify for an Impairment Award”

Impairment Benefits Response Sheet

         Activities of Daily Living Questionnaire

Claim No.

Claimant:

Impairment Benefits

Response Sheet

YES, I wish to pursue a claim for impairment benefits for the following covered illness(es). 

                                    _________________________________________

                                    _________________________________________

                                    _________________________________________

Additionally, please check the appropriate box(es) below:

  I am submitting or have submitted all available medical evidence, including Activities of Daily Living (ADL’s) and request that the District Office continue processing my impairment claim.  (If you are submitting current medical evidence, please be sure to attach it to this response sheet.)

  I am requesting current medical evidence from my treating physician and will submit this evidence by      .

  I wish for my treating physician to complete my impairment evaluation.  I have provided his/her name and address below.

Name:            

Address:       

Phone No.:     (          )                                                          

NO, I do not wish to pursue a claim for impairment at this time.  I understand that I can pursue an impairment rating in the future, if I choose to do so.

Signature Required

Signature                 Date

Please mail response to:            DEEOIC – Unit                       or FAX to (     )     

 Impairment Rating Requirements

If you elect to file an impairment claim, you will be required to provide Activities of Daily Living (ADL), along with the required medical records dated preferably within the last 12 months. 

The ADLs must be provided by your Specialist Physician, Family Practitioner or Primary Physician in a letter or should be noted in your medical records (for example, History and Physical Examination) in order for the impairment rating to be performed.  For your convenience, please take the attached ADL Questionnaire to your treating physician for his/her completion.  Please remember your medical records and diagnostic examinations must include your current treatments and prescribed medications.  This information should be dated within the last 12 months.  However, if you have no additional medical records to provide, please inform our office in writing, so that we can proceed with your impairment claim.

Since you will not be physically examined by a District Medical Consultant (DMC), obtaining your current medical records and ADLs from your physician is important in determining your rating.  The lack of medical information, to include ADLs, could potentially affect your impairment rating.  Below is an example of the ADL information needed from your physician, as referenced in the AMA’s Guides, Table 1-2.   

Table 1-2  Activities of Daily Living Commonly Measured                   in Activities of Daily Living (ADL) and                   Instrumental Activities of Daily Living (IADL) Scales
Activity	Example
Self-care, personal hygiene	Urinating, defecating, brushing teeth, combing hair, bathing, dressing oneself, eating
Communication	Writing, typing, seeing, hearing, speaking
Physical activity	Standing, sitting, reclining, walking, climbing stairs
Sensory function	Hearing, seeing, tactile feeling, tasting, smelling
Nonspecialized hand activities	Grasping, lifting, tactile discrimination
Travel	Riding, driving, flying
Sexual function	Orgasm, ejaculation, lubrication, erection
Sleep	Restful, nocturnal sleep pattern

Activities of Daily Living Questionnaire (Please note: This document must be completed by a physician)	Name:
	File Number:

Accepted Conditions	ICD-9 Code	Condition @ MMI[1]	Rating Scale (Each criteria is graded in level of dependence)     1 – Performs independently without reminder or assistance     2 – Performs with assistance or reminders     3 – Unable to perform on own, even if assisted
		Yes   No
		Yes   No
		Yes   No
See attached if more than 3 conditions
Is the claimant terminal?   YES   NO    If YES, estimated timeframe:  _____________________________________________

Since the employee will not be physically evaluated for impairment by a Department of Labor physician, the following information regarding the employee’s Activities of Daily Living (ADL) is required.  Rate the activity based only on limitations caused or contributed to by the accepted condition(s).  Address all items using the above rating scale to determine the person’s ability to perform the activity. 

Self-Care / Personal Hygiene		Rating	Additional comments concerning these activities
	Dressing/undressing oneself
	Eating
	Meal preparation
	Taking or managing medicine
	Toileting – getting to and on/off toilet
	Toileting – keeping self clean and dry
	Toileting – arranging clothes
	Bladder/Bowel control
	Brushing teeth
	Combing/brushing hair
	Bathing
	Light housekeeping

Communication		Rating	Additional comments concerning these activities
	Writing
	Typing
	Seeing
	Hearing
	Speaking

Physical Activity		Rating	Additional comments concerning these activities
	Standing
	Sitting
	Reclining
	Walking
	Climbing Stairs

Sensory Function		Rating	Additional comments concerning these activities
	Hearing
	Seeing
	Tactile Feeling
	Tasting
	Smelling

Other:  Non-specialized hand activities		Rating	Additional comments concerning these activities
	Grasping
	Lifting
	Pulling/Pushing
	Reaching up, down, out
	Tactile Discrimination

Travel		Rating	Additional comments concerning these activities
	Riding
	Driving
	Flying
	Arranging travel for self

Transferring In and Out of:		Rating	Additional comments concerning these activities
	Bed
	Tub/Shower
	Chair/Sofa
	Vehicles

Sexual Function		Yes	No	Additional comments concerning these activities
	Orgasm
	Ejaculation
	Lubrication
	Erection

Sleep		Yes	No	Additional comments concerning these activities
	Restful
	Nocturnal Sleep Pattern

Provide any additional comments to explain what this person can or cannot do in their daily life (if additional space is needed, please provide a typed narrative report and attach it to this questionnaire):

The information listed above is complete and accurate to the best of my knowledge:

Physician’s Printed Name
Physician’s Signature	Date

Activities of Daily Living Supplementary ADL Specific to:  Breast Cancer	Name:
	File Number:

Is the patient at MMI for breast cancer and if so what date?  MMI   Yes   No    Date: 

1. Was removal of part or all of one or both breast required?  If so, describe.

2. Is there resulting lymphoedema in the affected arms?  If so, describe severity.  Is it partially or completely controlled with stockings?

3. Is there a resulting decrease of motion in affected extremities?  If so, detail range of motion for those joints.

4. Is there any decrease in strength in the upper extremities?  If so, describe on a scale of 0-5 with mention of involved motor nerves.

5. Is there decreased sensation in the affected extremities?  If so, describe with mention of which sensory nerves.

6. Is there any intermittent or continuous pain of the chest wall?   If so, describe.

7. Has there been metastasis?  If so, describe.

Additional Comments:

Activities of Daily Living Supplementary ADL Specific to:  Skin Cancer	Name:
	File Number:

Is the patient at MMI for skin cancer and if so what date?  MMI   Yes   No    Date: 

1. Is the claimant limited to sun exposure?  If so, describe.

2. Does the claimant have a significant deformity from the skin cancer affecting interpersonal relationships?  If so, please describe.

3. Does the claimant have a deformity or scarring that limits range of motion of any joints?  If so, please state joint and indicate range of motion.

4. Does the claimant require use of a prescriptive drug for the treatment of skin cancer, either intermittently or continuously?  If so, please describe.

5. Does the claimant’s skin cancer limit any ADL other than sun exposure?  If so, please describe.

6. Has there been metastasis?  If so, please describe.

Additional Comments:

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[1] Condition has reached maximum medical improvement (MMI) i.e. well-stabilized and unlikely to improve with medical treatment or not required if an illness is in a terminal stage.