Division of Energy Employees Occupational Illness Compensation Policy Branch
Licensed Medical Care Provider Complaint Form
| Section I – Information | |||||||||
| This form is used to refer complaints about licensed medical care providers to the Program Integrity Unit. Complete the following sections of this form. Instructions are attached for reference. Once completed, email the form and any attachments to DEEOIC-INT-PA@dol.gov . | |||||||||
| Section II – District or Final Adjudication Branch Contact Information | |||||||||
| 1. Submitting Office: |
| 2. Submission Date: |
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| 3. Name of Submitter: |
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| 4. Contact Email: |
| 5. Contact Phone #: |
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| Section III - Complaint Background Information | |||||||||
| 6. Claim ID#: |
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| 8. Name of Provider (Company/Individual) Complaint is directed: |
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| Section IV – Describe the Complaint | |||||||||
| 9. Provide a discussion of the circumstances of the complaint including relevant date(s), times(s), place(s), names of parties involved, witnesses:
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Version 1.0
2018.4
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Instructions for Completing the Licensed Medical Care Provider Form |
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Read these instructions to complete the Licensed Medical Care Provider Complaint Form
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| Section I - Information – Referral submittal instructions. Email the completed form to |
| Section II – District or Final Adjudication Branch Contact Information
1. Submitting Office – District or Final Adjudication Office submitting the form.
2. Submission Date – Date that the form is completed for referral.
3. Name of Submitter – Name of the staff person submitting the form.
4. Contact email – Email address of the staff person submitting the form.
5. Contact Phone – Work telephone number of the staff person submitting the form.
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| Section III - Complaint Background Information
6. Claim ID# – Identify the case ID# or leave blank if no specific case is involved.
7. Claimant name – List the claimant involved or leave blank if no specific claimant is involved.
8. Name of provider (Company/Individual Complaint is Directed) – provide the name of the provider for which the complaint is being filed. The name of the provider can be a company or person rendering professional care for a DEEOIC claimant.
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| Section IV – Describe the Complaint
9. Provide a description of the issue or concern directed at a medical provider. Describe any relevant information about the situation including date/time, location, and person(s) involved. You may attach a supplemental statement if more space is required. |
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