FECA Medical Report Forms, Claim for Compensation

U.S. DEPARTMENT OF LABOR

EMPLOYMENT STANDARDS ADMINISTRATION

OFFICE OF WORKERS' COMP PROGRAMS

PO BOX 8300 DISTRICT XX

LONDON, KY 40742-8300

Phone: (XXX) XXX-XXXX

Date

Date of Injury:

Employee:

Dear Sir/Madam:

This Office is in receipt of a request for the services of an attendant. For the purpose of making a decision as to whether payment for services of an attendant can be authorized, additional information is needed from you as well as your treating physician. Along with this letter, you will find two enclosures. The first is a list of questions to which you are asked to respond. The second is a questionnaire for completion by your physician.

If services are approved, payment for such services is limited to $1500 per month by regulation. Payments are to be billed by and paid directly to the professional providing attendant services. Such services are to be rendered by a home health aide, licensed practical nurse or similarly trained individual.

Please be advised that 20 CFR 10.314 allows payment for services of an attendant where medical documentation supports that you require assistance to care for basic personal care needs. The Federal Employees' Compensation Act allows no provision for payment of tasks such as cooking, laundry, housekeeping, shopping, or yard work.

Sincerely,

OMB No. 1215-0103 Expires: 10-31-2008

Employee:

Case Number: XXXXXXXXX

Please respond to the following questions.

1. State why you believe you require the services of an attendant. Identify the specific activities with which you require assistance. How does your condition render you incapable of performing these activities on your own?

2. Give the approximate amount of time you believe an attendant will be required. (State your answer in number of hours per day and number of days per week.)

3. If you wish to have a specific individual provide attendant services, state the name and address of that person. Indicate what qualifies that person to be an attendant and cite any credentials that person has. If that person is a family member, state his/her relationship to you.

4. Are you currently in receipt of attendant services? If so, state how long you have had attendant services. Indicate how much your attendant is paid per month. If not paid in cash or if only partially paid in cash, indicate what the reasonable monthly value of the services rendered by your attendant is?

I hereby certify that the information given by me and in connection with this questionnaire is true and correct to the best of my knowledge and belief.

Signed __________________________________________ Date ________________

Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain compensation as provided by the FECA or who knowingly accepts compensation to which that person is not entitled is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by fine or imprisonment, or both.

Employee:

Case Number: XXXXXXXXX

Note to treating physician: Additional information is needed to determine whether the disability of the federal employee you are treating warrants the services of an attendant. Please complete the enclosed questionnaire and return it promptly to this Office. If you need more space, use a separate sheet of paper and number your answers to correspond with the questions.

1. When did you most recently examine the employee named above?______________

What were the findings upon examination? ______________________________________________________ _______________ ______________________________________________________________________

2. Explain why you believe the employee's condition warrants the services of an attendant. ______________________________________________________________________ ______________________________________________________________________

3. How long do you believe the employee will require the services of an attendant? ______________________________________________________________________ ______________________________________________________________________

4. Is the employee living at home? Yes __________ No ________________

5. Is the employee living in an institution? Yes __________ No ___________

If so, give the name and address of the institution: ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

6. If the employee now has the services of an attendant, what is the name and relationship of the attendant to the employee (if related)? __________________________________________

7. Is the employee able to: (Check one box after each item)

Unassisted Assisted Not at All

(a) Travel? ( ) ( ) ( )

(b) Walk? ( ) ( ) ( )

(c) Feed himself/herself? ( ) ( ) ( )

(d) Dress himself/herself? ( ) ( ) ( )

(e) Bathe himself/herself? ( ) ( ) ( )

(f) Get out of bed? (If so, state number ( ) ( ) ( )

Of hours per day___________)

(g) Get out of doors? (If so, state to ( ) ( ) ( )

What extent:_________________)

(h) Take exercise? (If so, state to ( ) ( ) ( )

What extent:_________________)

If the answer to any of the above items is 'Not at All', please give detailed reasons. ______________________________________________________________________ ______________________________________________________________________

7. If the employee now has the services of an attendant, identify the actual duties performed by the attendant: ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

8. Outline all other facts with reference to the employee's behavior or activity which are pertinent to the need for an attendant: ______________________________________________________________________

______________________________________________________________________

9. I certify that all statements in response to the questions asked on this form are true, complete and correct to the best of my knowledge. I further understand that any knowingly false statement, misrepresentation or concealment of fact may subject me to felony criminal prosecution.

(Signature) _________________________________ (Date) ______________________

NOTICE TO RECIPIENT

Privacy Act

The authority for requesting this information is 5 U.S.C. 8101 et seq. The information will be used to determine entitlement to benefits. Furnishing the requested information is required for the claimant to obtain or retain a benefit. Information collected will be handled and stored in compliance with the Freedom of Information Act, the Privacy Act of 1974, as amended (5 U.S.C. 552a). Failure to furnish the requested information may delay the processing of the claim or the payment of benefits, or may result in an unfavorable decision or reduced level of benefits.

Public Burden Statement

Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

We estimate that it takes an average of 10 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 S-3229, 200 Constitution Avenue, NW, Washington, DC 20210.

DO NOT SEND THE INFORMATION REQUESTED TO THE ADDRESS SHOWN JUST ABOVE. RATHER, SEND IT TO THE ADDRESS SHOWN ON THE LETTERHEAD.