SAMPLE ANCILLARY MEDICAL SERVICES AUTHORIZATION LETTER
Date:
Claimant Name (or Auth Rep)
Street Address
City, State, Zip
Re: Case ID [Enter Case ID Number]
Dear [Enter Claimant or Auth Rep Name]:
This letter is in reference to your claim for benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA).
The Division of Energy Employees Occupational Illness Compensation (DEEOIC) recently received a request for authorization for [Enter the ancillary medical service] for the following covered medical condition(s):
List the covered condition(s):
After a thorough review of your case file, including communication with your treating physician (if applicable), the following authorization is granted:
[Enter type of ancillary medical service and billing code(s)] for the period of [Enter to and from date] from [Enter vendor name].
Note that the DEEOIC requires that the approved vendor noted above be enrolled as a provider in our medical bill payment system to be reimbursed. Vendors may call toll free 1-866-272-2682 for program enrollment information or for answers to payment questions.
All fees for the ancillary medical service is subject to the OWCP Fee Schedule.
If you have any questions or concerns regarding this authorization, please call your claims examiner at (XXX) XXX-XXXX.
Sincerely,
[Enter CE name]
DEEOIC Claims Examiner
cc: [Enter supplier name]