Sample Home Modification Letter






[Claimant Name or AR Name]

[Street Address]

[City, State, Zip]




Case ID:

[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).


The Division 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:

If you have any questions or concerns regarding this authorization please call me at [Insert Telephone Number].




[Enter CE Name]

Claims Examiner




Copy To: Authorized Representative


Copy To: Contractor