Esa-30

DOL Privacy Act systems ESA-30.pdf

Certificate of Medical Necessity

ESA-30

OMB: 1240-0024

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16878

Federal Register / Vol. 67, No. 67 / Monday, April 8, 2002 / Notices

SAFEGUARDS:

RECORD SOURCE CATEGORIES:

Material in the possession of the
Office of Workers’ Compensation
Programs and its contractors will be,
when not in use, kept in closed file
cabinets, appropriate lockers and
storage areas, etc.

Information in this system is obtained
from Federal, state or local government
agencies, state licensing boards,
professional organizations, claimants,
patients, employers, insurance
companies, any other entities or
individuals, public documents, and
newspapers, as well as from other
Department of Labor systems of records.

RETENTION AND DISPOSAL:

File is retained in the office for three
years after the debarment action is final
and then transferred to the Federal
Records Center, and destroyed thirty
years after the debarment action is final.
Where the period of exclusion is
defined as a set period of time, the file
will be retained two years after the
period of exclusion expires (or the
individual is otherwise reinstated), then
transferred to the Federal Records
Center, and destroyed thirty years after
the debarment action is final.
SYSTEM MANAGER(S) AND ADDRESS:

Director for Federal Employees’
Compensation, Office of Workers’
Compensation Programs, 200
Constitution Avenue, NW, Washington,
DC 20210, and the District Directors of
the district offices set forth in the
Appendix to this document.
NOTIFICATION PROCEDURE:

An individual wishing to inquire
whether this system of records contains
information about him/her may write
the appropriate system manager at the
address above. In order for the record to
be located, the individual must provide
his or her full name, date of birth, and
signature.
RECORD ACCESS PROCEDURE:

Any individual seeking access to nonexempt information about a record
within this system of records may write
the OWCP district office where the case
is located, or the system manager, and
arrangements will be made to provide
review of the file. In order for the record
to be located, the individual must
provide his or her full name, date of
birth, and signature.
CONTESTING RECORD PROCEDURE:

Specific materials in this system have
been exempted from certain Privacy Act
provisions regarding the amendment of
records. The section of this notice
Entitled ‘‘Systems Exempted from
Certain Provisions of the Act’’ indicates
the kind of materials exempted, and the
reasons for exempting them. Any
individual requesting amendment of
non-exempt records should contact the
appropriate the system manager.
Individuals requesting amendment of
records must comply with the
Department’s Privacy Act regulations at
29 CFR 71.1 and 71.9.

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SYSTEM EXEMPTED FROM CERTAIN PROVISIONS
OF THE ACT:

In accordance with 5 U.S.C.
552a(k)(2), investigatory material
compiled for law enforcement purposes
which is maintained in the investigation
files of the Office of Workers’
Compensation Programs, is exempt from
subsections (c)(3), (d), (e)(1), (e)(4)(G),
(H), and (I), and (f) of 5 U.S.C. 552a. The
disclosure of information contained in
civil investigative files, including the
names of persons and agencies to whom
the information has been transmitted,
would substantially compromise the
effectiveness of the investigation.
Knowledge of such investigations would
enable subjects to take such action as is
necessary to prevent detection of illegal
activities, conceal evidence or otherwise
escape civil enforcement action.
Disclosure of this information could
lead to the intimidation of, or harm to,
informants and witnesses, and their
respective families, and the well being
of investigative personnel and their
families.
DOL/ESA–30
SYSTEM NAME:

Office of Workers’ Compensation
Programs, Black Lung Automated
Support Package.
SECURITY CLASSIFICATION:

SYSTEM LOCATION:

Office of Workers’ Compensation
Programs, Division of Coal Mine
Workers’ Compensation, U.S.
Department of Labor Building, 200
Constitution Ave., NW, Washington, DC
20210, and district offices (see addresses
in the Appendix to this document).
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:

Individuals filing claims for black
lung benefits; claimants receiving
benefits; dependents of claimants and
beneficiaries; medical providers;
attorneys representing claimants; coal
mine operators (workers’ compensation
insurance carriers).
CATEGORIES OF RECORDS IN THE SYSTEM:

Records included are personal (name,
date of birth, SSN, claim type, miner’s

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AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

30 U.S.C. 901 et seq., 20 CFR 715.1 et
seq., 20 CFR 720.1 et seq., 20 CFR 725.1
et seq.
PURPOSE(S):

To maintain data on claimants,
beneficiaries and their dependents;
attorneys representing claimants;
medical service providers; coal mine
operators and insurance carriers.
Provide means of automated payment of
medical and disability benefits.
Maintain a history of medical bills
submitted by beneficiaries and medical
service providers. Maintain a history of
disability benefit payments made to
beneficiaries and medical benefit
payments made to beneficiaries and
medical service providers. Maintain
program accounting information
including information on debts owed to
the United States. Provide a means for
the automatic recoupment of
overpayments made to beneficiaries and
medical service providers.
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:

Unclassified.

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date of death); demographic (state,
county, city, congressional district, zip
code); mine employment history;
medical records; initial determination;
conference results; hearing results;
medical and disability payment history;
accounting information including data
on debts owed to the United States;
Social Security Administration black
lung benefits data; state workers’
compensation claim and benefits data;
coal mine operator names, addresses,
states of operation and histories of
insurance coverage; and medical service
providers names, addresses, license
numbers, medical specialties, tax
identifications and payment histories.

In addition to those universal routine
uses listed in the General Prefatory
Statement to this document , disclosure
of relevant and necessary information
may be made to the following:
a. Mine operators (and/or any party
providing the operator with workers’
compensation insurance) who have
been determined potentially liable for
the claim at any time after the filing of
a notice of injury or claim related to
such injury or occupational illness, for
the purpose of determining liability for
payment.
b. State workers’ compensation
agencies and the Social Security
Administration for the purpose of
determining offsets as specified under
the Act.
c. Doctors and medical services
providers for the purpose of obtaining

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Federal Register / Vol. 67, No. 67 / Monday, April 8, 2002 / Notices
medical evaluations, physical
rehabilitation or other services.
d. Other Federal agencies conducting
scientific research concerning the
incidence and prevention of black lung
disease.
e. Legal representatives, or person
authorized to act on behalf of the
claimant, responsible operator and
program representation on contested
issues.
f. Labor unions and other voluntary
employee associations of which the
claimant is a member for the purpose of
exercising an interest in claims of
members as part of their service to the
members.
g. Contractors providing automated
data processing services to the
Department of Labor, or to any agency
or entity to whom release is authorized,
where the contractor is providing a
service relating to the purpose for which
the information can be released.
h. Federal, state or local agencies if
necessary to obtain information relevant
to a Department decision concerning the
determination of initial or continuing
eligibility for program benefits, whether
benefits have been or are being paid
improperly, including whether dual
benefits prohibited under any federal or
state law are being paid; and salary
offset and debt collection procedures,
including any action required by the
Debt Collection Act of 1982, 31 U.S.C.
3711.
i. Debt collection agency that DOL has
contracted for collection services to
recover indebtedness owed to the
United States.
j. Internal Revenue Service for the
purpose of obtaining taxpayer mailing
addresses in order to locate taxpayers to
collect, compromise, or write-off a
Federal claim against the taxpayer;
discharging an indebtedness owed by an
individual.
k. Credit Bureaus for the purpose of
receiving consumer credit reports
identifying the assets, liabilities, income
and expenses of a debtor to ascertain the
debtor’s ability to pay a debt and to
establish a payment schedule.

taxpayer identification (SSAN), and
other information necessary to establish
the identity of a debtor, the agency and
program under which the claim arose,
are disclosed pursuant to 5 U.S.C.
552a(b)(12) to consumer reporting
agencies as defined by section 603(f) of
the Fair Credit Reporting Act (15 U.S.C.
1681a(f); or in accordance with section
3(d)(4)(A)(ii) of the Federal Claims
Collection Act of 1966 as amended (31
U.S.C. 3711(f) for the purpose of
encouraging the repayment of an
overdue debt.
POLICIES AND PRACTICES FOR STORING,
RETRIEVING, ACCESSING, RETAINING, AND
DISPOSING OF RECORDS IN THE SYSTEM:
STORAGE:

Magnetic media. Medical bills and
supporting medical reports transferred
to microfilm and magnetic media.
RETRIEVABILITY:

Coal miner’s name and social security
number; medical provider number; coal
mine operator number; insurance carrier
number.
SAFEGUARDS:

Files secured in a guarded facility;
teleprocessing access protected by
restrictions on access to equipment and
through use of encrypted passwords.
RETENTION AND DISPOSAL:

Electronic file data has permanent
retention. Claimant and benefit master
file data will be transferred to magnetic
tape and transmitted to NARA every ten
years. This data (which includes both
open and closed cases) will not be made
available to the public until 90 years
after transfer to NARA due to Privacy
Act restrictions.
SYSTEM MANAGER(S) AND ADDRESS:

Director, Division of Coal Mine
Workers’ Compensation, U.S.
Department of Labor, Room C–3520, 200
Constitution Ave., NW, Washington, DC
20210, and district office director (see
addresses in The Appendix to this
document).

Note: Disclosure of information contained
in the file to the claimant, a person who is
duly authorized to act on his/her behalf, or
to others to whom disclosure is authorized by
these routine uses, may be made over the
telephone. Disclosure over the telephone will
only be done where the requestor provides
appropriate identifying information.
Telephonic disclosure of information is
essential to permit efficient administration
and adjudication of claims.

NOTIFICATION PROCEDURE:

DISCLOSURE TO CONSUMER REPORTING
AGENCIES:

Individuals wishing to access any
records should contact the appropriate
office listed in the Notification
Procedure section. Individuals must

The amount, status and history of
overdue debts; the name and address,

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Individuals wishing to inquire
whether this system of records contains
information about them should contact
the system manager at the above address
or district office director (see addresses
in the Appendix to this document).
Individuals must furnish their name,
address, and signature.
RECORD ACCESS PROCEDURES:

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furnish their name, address and
signature.
CONTESTING RECORD PROCEDURES:

Individuals wishing to request
amendment of any non-exempt records
should contact the appropriate office
listed in the Notification Procedure
section. Individuals must furnish their
name, address, and signature.
RECORD SOURCE CATEGORIES:

Individuals, and organizations.
SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS
OF THE ACT:

Investigatory portion of system
exempted from certain provisions of the
ACT: In accordance with paragraph
3(k)(2) of the Privacy Act, investigatory
material compiled for civil law
enforcement purposes, which is
maintained in this system’s files of the
Office of Workers’ Compensation
Programs of the Employment Standards
Administration, is exempt from
paragraphs (c)(3), (d), (e)(1), (e)(4)(G),
(H), and (I), and paragraph (f) of 5 U.S.C.
552a. The disclosure of civil
investigatory information, if any,
contained in this system’s files,
including the names of persons and
agencies to whom the information has
been transmitted, would substantially
compromise the effectiveness of
investigations. Knowledge of such
investigations would enable subjects to
take such action as is necessary to
prevent detection of illegal activities,
conceal evidence, or otherwise escape
civil enforcement action. Disclosure of
this information could lead to the
intimidation of, or harm to informants,
witnesses, and their respective families,
and in addition, could jeopardize the
safety and well-being of investigative
personnel and their families.
DOL/ESA–32
SYSTEM NAME:

ESA, Employee Conduct
Investigations.
SECURITY CLASSIFICATION:

None.
SYSTEM LOCATION:

The Employment Standards
Administration National Office.
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:

Subjects of complaints and/or
investigations covered under the
authority delegated to the Branch of

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File Typeapplication/pdf
File TitleDocument
SubjectExtracted Pages
AuthorU.S. Government Printing Office
File Modified2005-04-04
File Created2005-04-04

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