Sample Medical Development Letter (CLAIMANT)

(Date)

 

Dear (Insert Employee Name):

We recently received a claim requesting that home health care services be provided to you under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). You have previously been awarded medical benefits, which may include home health care services, for the following work-related conditions: [Insert Accepted Medical Conditions]

After a careful review of your claim, we have determined that additional medical evidence is needed in order to evaluate your request. We have written to your doctor requesting the additional information that we require. A copy of our letter is attached.

Please contact your doctor’s office to confirm that they received our request, and that a response will be provided. If you believe that our request should be directed to a doctor other than the one identified in this attached letter, please contact me right away.

Ultimately, it is your responsibility to make certain that we receive the medical information needed in support of your request. We are asking that you and your physician provide us with a response within the next 30 days.

If you have any questions, or need to contact me regarding this letter, please call me at 1-888-XXX-XXXX.

Sincerely,

(Insert Name)

Claims Examiner

Encl. Letter to Physician

______________________________________________________________________________________

If you have a disability (a substantially limited physical or mental impairment); please contact our office/claims examiner for information about the kinds of help available, such as communication assistance (alternate formats or sign language interpretation), accommodations and modifications.