Sample Home Modification Letter
Name or AR Name]
[Insert Employee Name]
Dear [Insert Employee or AR Name]:
This letter is
in reference to your claim for medical benefits under the Energy Employees
Occupational Illness Compensation Program Act (EEOICPA).
of Energy Employees Occupational Illness Compensation (DEEOIC) recently
received an authorization request for home modifications related to your
accepted medical condition(s).
Along with your request we
also received a copy of your letter of medical necessity, prescribing [Insert
brief description of modifications prescribed by letter of medical necessity].
Additionally, we received the two, detailed contractor estimates, describing
the scope and cost of the proposed modifications.
After a careful review of
your request, we have determined that the evidence submitted is sufficient to
authorize your request for home modification. The request is approved subject
to the following conditions:
- The DEEOIC is approving
modifications based upon the proposal submitted by: [Insert Name and
Address of Contractor and Date of Proposal, for the approved bid.]
- The total approved cost
for all work, including materials, labor, profit and overhead is the
amount of [Insert Approved Dollar Amount] as stated in the
- Upon completion of the
approved modifications, you must submit a signed letter to DEEOIC advising
that all of the approved work has been completed, and that the work has
been completed in a satisfactory manner. Along with your letter you must
submit a completed OWCP Form 915 (Claim For Medical Reimbursement), a
final invoice for the charges billed, and proof of payment to the
- If you want DEEOIC to
pay the contractor directly, it will be necessary for the contractor to enroll in our medical bill processing
system in order to receive payment. Contractors seeking additional
enrollment information can call our toll-free number (866-272-2682) for answers
to billing questions. Once the approved work has been completed, it will
be necessary for you to write us advising that all work has been completed
in a satisfactory manner, and that you are requesting DEEOIC to make
payment directly to the contractor, for the pre-approved amount.
- Once DEEOIC has
approved a written proposal for medically necessary modifications, you
have the option of contracting for additional modifications, or for
materials and appliances that represent an upgrade from the medically
necessary standard prescribed. You may do so with the understanding that
DEEOIC will only reimburse you for the cost of medically necessary
modifications approved in writing. Reimbursement for the approved amount
will be made to you upon completion of all work, and upon receipt of the
- A letter from you
stating that all work, as detailed in the approved modification proposal,
has been completed to your satisfaction.
- A final invoice from
the contractor itemizing the cost of the completed work.
- Proof of payment to
the contractor for an amount no less than the amount approved for
reimbursement by DEEOIC.
- The DEEOIC neither
endorses nor sponsors any entity providing services to beneficiaries of
If you have
any questions or concerns regarding this authorization
please call me at [Insert Telephone Number].