U.S. Department of Labor
Employment Standards Administration
Office Of Workers’ Compensation Programs
Division of Energy Employees’ Compensation
EMPLOYEE: employee name
City, State, zip
Dear Medical Provider;
The Department of Labor, Division of Energy Employees Occupational Illness Compensation (DEEOIC), District Office, has received a claim from employee name and has determined that employee name is eligible for an impairment evaluation in relation to the covered illness of Insert name AND ICD9 of covered illness.
Employee name has identified you as his/her choice to perform an impairment evaluation in relation to his/her covered illness of Insert name AND ICD9 of covered illness. The DEEOIC will cover the cost of Employee name impairment evaluation as long as the condition has reached a point where further improvement is not expected (Maximum Medical Improvement/MMI), or the employee is considered to be in the terminal stages of the illness. The evaluation must also be performed within one year of the date DEEOIC receives the report, and not performed prior to Filing date (the date he/she filed for benefits under the EEOICPA). The evaluation must be performed in accordance with the 5th Edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment (AMA’s Guides), with specific page and table references included in your report.
In order for a physician to be deemed qualified, he/she must hold a valid medical license and Board certification/eligibility in the appropriate field of expertise (i.e. toxicology, pulmonary, neurology, occupational medicine, etc.). He/she must also show that he/she meets at least one of the following criteria:
When your impairment evaluation has been completed, please submit a resume or letter to establish that you meet the criteria listed above. If you do not possess either the ABIME or AADEP certification, please submit a statement certifying and explaining your familiarity and years of experience in using the AMA’s Guides.
Please note that in agreeing to perform the impairment rating evaluation, you are stating and certifying that no more than 25% of your income in any of the five previous years has come from serving as a salaried employee, consultant or expert witness for employers, insurers, unions, claimant organizations or
their counsel in litigation related to the Energy Employees Occupational Illness Compensation Program or similar state compensation programs.
Payment for the impairment evaluation and required diagnostic tests are covered by the DEEOIC. To bill the Department of Labor directly, please complete and return the enclosed EEOICP Provider Enrollment Form (OWCP-1168) and the OWCP-1500, to the district office in the enclosed self addressed envelope.