[Authorization Letter]




Claimant (or Auth Rep) Name

Street Address

City, State, ZIP


Re: Claim Number: (Insert Claim Number)


Dear Claimant (Insert Claimant or Auth Rep Name):


This letter is in reference to your claim for compensation under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).


The Division of Energy Employees Occupational Illness Compensation (DEEOIC) recently received a request for authorization of in-home medical care for the following covered medical conditions:


Pulmonary Fibrosis


Chronic Obstructive Pulmonary Disease (COPD)


After a thorough review of your case file including communication with your treating physician [if applicable] the following authorization is granted for the period of December 4, 2006 through June 4, 2007:


Registered Nurse [Billing Codes T1030 (per diem) and S9123 (hourly)] to administer medication and conduct physical evaluation 1 hour per day, every 5 days.


Home Health Aid or equivalent [Billing Codes T1021 (per diem) and S9122 (hourly)], 16 hours per day, seven days per week, to assist with ambulating, bathing, general personal hygiene, food preparation and feeding, and oxygen canister replacement.


You are free to select any licensed provider willing to perform the authorized services; however, the DEEOIC requires that the provider be enrolled in our medical bill payment system. Providers may call toll free 1-866-272-2682 for program enrollment information or for answers to payment questions.


If you have any questions or concerns regarding this authorization please call your claims examiner at (XXX) XXX-XXXX.





(Insert POC CE Name)

DEEOIC Claims Examiner




Cc: Provider