Claimant Name (or Auth Rep/provider)  File Number

Street Address                        Accepted Conditions

City, State, Zip



Dear (Insert Claimant or Auth Rep/Provider Name):


I am writing to you concerning your benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). We have received a request for authorization for the [rental/purchase] of a [enter type of DME requested].  In order to properly evaluate and respond to this request, we need additional information from you.


Please provide our office with the following information:


(Request only that information that is necessary to process the claim. Feel free to modify the following if necessary)


·        Prescription from your treating physician.

·        Letter of Medical Necessity or other medical documentation [Describe the general information a LMN is to provide. Refer to Item #3 of the Bulletin].

·        Claimant information such as name, case file number, date of birth, and telephone number.

·        Provider or vendor information such as name, provider address, ACS provider number, tax id number, national provider identification number, telephone number, and fax number.

·        Treating physician contact information such as name, address, telephone number, and fax number.

·        DME information such diagnosis code, HCPCS/CPT, modifier, quantity, purchase price, rental price, total cost, begin date, end date, and duration of use.


Please note that add-ons and/or upgrades to DME will be considered for approval if evidence substantiates a medical need for the enhancement.  However, add-ons and/or upgrades to DME are not covered when they are intended primarily for the claimant’s convenience and do not significantly enhance DME functionality.


In the interest of expediting the approval of your request for [enter type of DME], please fax the requested information to the DEEOIC Bill Processing Agent at (800) 882-6147, within 30 days, or contact me if you have questions regarding this request.


Thank you for your assistance.






[Insert POC CE Name and Signature]

[Insert POC CE Telephone and Fax Numbers]


Cc: [Enter as appropriate]