Date

Case ID Number:

Employee:

Name

Address

Address

Dear Mr./Mrs. Last Name:

I am writing to inform you that we are unable to make a determination on your claim for impairment benefits under Part E of the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).

In order to determine whether you have sustained a permanent impairment, the physician must conclude that your accepted condition is well stabilized and unlikely to improve substantially with or without medical treatment; this is called maximum medical improvement or MMI. The medical evidence shows your condition has not reached this state; therefore, we cannot determine your impairment rating at this time.

Your impairment claim will be administratively closed until your condition has reached MMI. At that time, please submit your physician’s opinion and we will reopen your impairment claim and resume development.

If at any time you would like to discuss this issue further, please do not hesitate to contact our office, toll-free, at ( ) . If it is more convenient, you may visit one of our local resource centers for additional help.

Sincerely,

Printed Name

Claims Examiner