EE-17B Physician's Certification of Necessity Under the EEOICPA

U.S. Department of Labor
Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Illness Compensation

PHYSICIAN’S CERTIFICATION OF MEDICAL
NECESSITY UNDER THE ENERGY EMPLOYEES
OCCUPATIONAL ILLNESS COMPENSATION
PROGRAM ACT
Instructions

Provide the identifying information requested below, indicate the date of your face-to-face physical examination
of your patient, check either the box requesting an in-home assessment or the other box indicating you are
attaching a Letter of Medical Necessity, have your physician sign and date the bottom of this form and mail it to
U.S. Department
of Labor,, OWCP/DEEOIC,, P.O. Box 8306,, London,, KY 40742-8306. Alternatively,
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SHADED AREAS. For additional instructions, see page 2.

OMB Control No. 1240-0002
Expiration Date: XX/XX/2024

Patient Information
Date of Birth:

Name (Last, First, Middle Initial)

DEEOIC Case I.D.:
Address (Street, Apt. #, P.O. Box)

SSN: XXX-XX-

(Last Four Only)

Telephone Number(s)

(City, State, Zip Code)

Home: (
Other: (
Treating Physician Information
Physician Name (Last, First, Middle Initial)

Telephone Number(s):
Office: (

Address (Name of Facility, Street, Suite #, P.O. Box)

Other: (
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(City, State, Zip Code)

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DEEOIC Accepted Conditions

Date of Physician’s Examination, and Request for Assessment or Letter of Medical Necessity (check appropriate box)
Date of Face-to-Face
In-home Assessment Requested
Physical Examination:
Before prescribing home health care, nursing home or assisted living services for my patient, I am requesting an
in-home assessment to assist me in determining the need for services related to the accepted condition(s) listed
above.
Letter of Medical Necessity Attached
I have attached a Letter of Medical Necessity that contains both a plan of care and the rationale for my
conclusion that the prescribed home health care, nursing home or assisted living services are medically
necessary for treatment of the accepted condition(s) listed above.
Physician Declaration
By signing this Form EE-17B, I acknowledge that: the above-named patient is currently under my care for the DEEOIC accepted condition(s)
listed above; I have personally examined this patient on the date indicated above; I have read the DEEOIC Home Health Care Letter to
Physicians; I understand that DEEOIC only pays for care that is medically necessary for treatment of DEEOIC accepted conditions; and I
understand that DEEOIC cannot pay for care for any condition that may be a consequence of DEEOIC accepted condition(s) until specifically
claimed for and accepted by DEEOIC. I have attached copies of the relevant medical documentation and objective testing supporting my
attached Letter of Medical Necessity (if I have provided one).
Physician Signature

Date

Page 1

Form EE-17B
July 2024

Additional Instructions to Physician
Form EE-17B is used to obtain a Letter of Medical Necessity (LMN) from the treating physician that describes the claimant’s Home Health
Care (HHC) needs as they relate to one or more of the DEEOIC accepted conditions identified on this form. The LMN must state that you
have personally met with and examined your patient within the past 60 days and have made a determination as to the type of care, and
the frequency
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If you feel that you need more inforation from your patient before you can prepare the LMN, you may first wish to schedule a visit with
your patient to discuss his/her HHC needs. If you feel that an in-home assessment by a provider of HHC services would be of value,
please check the appropriate box on page 1, sign the Physician Certification at the bottom of the form and return it to the DEEOIC Central
Mail Room address below. Our claims staff will notify the HHC provider, designated by your patient, that an in-home assessment of HHC
needs has been authorized by DEEOIC. Once the assessment has been completed, our district office will forward a report to your office,
and you can proceed with preparing your LMN. Once you have the necessary information to prepare a LMN, here is the specific
information we are seeking:
Physical Examination: DEEOIC requires a physician to have personally visited with and conducted a physical examination of the
patient, within the past 60 days. Your LMN should provide a written narrative describing your physical findings at the time of
examination, and the specific functional limitations resulting exclusively from the accepted work-related illness.
Type and Duration of Care: The LMN must clearly specify the type(s) of HHC required, and for each type of care must specify the
number of hours per day, and number of days per week for that particular type of service. The letter must also provide a
description of the specific medical services to be performed by each type of caregiver. Examples of the various types of HHC
available are as follows:
Skilled Nursing Care (RN/LPN)
Home Health Aid/Personal Care Attendant
Respiration Therapist
Occupational/Physical Therapist

Privacy Act Statement
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees
Occupational Illness Compensation Program Act (42 USC 7384 et seq.) (EEOICPA) is administered by the Office of Workers’ Compensation
Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate families. (2)
Information received will be used to determine eligibility for, and the amount of, benefits payable under EEOICPA, and may be verified through
computer matches or other appropriate means. (3) Information may be disclosed to physicians and other healthcare providers for use in
providing treatment, performing evaluations for the Office of Workers’ Compensation Programs, and for other purposes related to the medical
management of the claim. (4) Information may be given to Federal, state, and local agencies for law enforcement purposes, to obtain
information relevant to a decision under EEOICPA, to determine whether benefits are being paid properly, including whether prohibited
payments have been made, and, where appropriate, to pursue debt collection actions required or permitted by the Debt Collection Act. (5)
Failure to disclose all requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable
decision.

Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to the information collections on this form unless it
displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 30 minutes per
response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing
the collection of information. You are not required to respond to this collection, but failure to respond may result in an unfavorable decision.
Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the U.S. Department of Labor, Office of Workers’ Compensation Programs, Room S3524, 200 Constitution Avenue N.W.,
Washington, D.C. 20210, and reference OMB Control No. 1240-0002 and Form EE-17B. DO NOT SUBMIT THE COMPLETED FORM TO
THIS ADDRESS.

Page 2

Form EE-17B
July 2024