System of Record Notice

System of Record Notice.pdf

Certificate of Medical Necessity

System of Record Notice

OMB: 1240-0024

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25858

Federal Register / Vol. 81, No. 83 / Friday, April 29, 2016 / Notices

SAFEGUARDS:

Access by authorized personnel only.
Computer security safeguards are used
for electronically stored data and locked
locations for paper files.
RETENTION AND DISPOSAL:

Records are retained for 10 years after
case is closed in accordance with the
applicable Records Schedule.
SYSTEM MANAGER(S) AND ADDRESS:

Director, Division of Coal Mine
Workers’ Compensation, Department of
Labor Building, 200 Constitution
Avenue NW., Washington, DC 20210.
NOTIFICATION PROCEDURE:

Inquiries should be mailed to the
System Manager or submitted in such
other manner as directed by OWCP.
RECORD ACCESS PROCEDURES:

A request for access should be mailed
to the System Manager or submitted in
such other manner as directed by
OWCP.
CONTESTING RECORD PROCEDURES:

A petition for amendment should be
mailed to the System Manager or
submitted in such other manner as
directed by OWCP.
RECORD SOURCE CATEGORIES:

Information contained in this System
is obtained from individuals, employers,
medical providers and investigators.
SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS
OF THE ACT:

None.
OWCP–2
SYSTEM NAME:

Office of Workers’ Compensation,
Black Lung Benefits Claim File.
None.
SYSTEM LOCATION:

Office of Workers’ Compensation
Programs, Division of Coal Mine
Workers’ Compensation, Department of
Labor Building, 200 Constitution
Avenue NW., Washington, DC 20210,
and district offices (see addresses in the
Appendix to this document).

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CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:

Individuals filing claims for black
lung (pneumoconiosis) benefits under
the provisions of Black Lung Benefits
Act, as amended, including miners, and
their surviving spouses, children,
dependent parents and siblings.
CATEGORIES OF RECORDS IN THE SYSTEM:

Personal (name, date of birth, social
security number, claim type, miner’s

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AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

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

To maintain records that are used to
process all aspects of claims for black
lung (pneumoconiosis) benefits under
the provisions of the Black Lung
Benefits Act, as amended, including
claims filed by miners and their
surviving spouses, children, dependent
parents and siblings. These records are
also used to process the recoupment of
overpayments under the Act.
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:

SECURITY CLASSIFICATION:

VerDate Sep<11>2014

date of death), medical, and financial.
Information gathered in connection with
investigations concerning possible
violations of Federal law, whether civil
or criminal, under the authorizing
legislation and related Acts. This record
also contains investigative records and
the work product of the Department of
Labor and other governmental personnel
and consultants involved in the
investigations. If the individual has
received benefits to which he or she is
not entitled, the system may contain
consumer credit reports correspondence
to and from the debtor, information or
records relating to the debtor’s current
whereabouts, assets, liabilities, income
and expenses, debtor’s personal
financial statements, and other
information such as the nature, amount
and history of a claim filed by an
individual covered by this system, and
other records and reports relating to the
implementation of the Debt Collection
Act of 1982 including any investigative
records or administrative review
matters. The individual records listed
herein are included only as pertinent to
the individual claimant.

Jkt 238001

In addition to those universal routine
uses listed in the General Prefatory
Statement of 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 benefits
insurance) who have been determined
potentially liable for the claim at any
time after the filing of a claim for Black
Lung Benefits 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
medical evaluations, physical
rehabilitation or other services.

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d. Other Federal agencies conducting
scientific research concerning the
incidence and prevention of black lung
disease.
e. Representatives of the claimant for
the purpose of processing the claim,
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
assisting the member.
g. Contractors providing automated
data processing services to the
Department of Labor, or to any agency
or entity to which 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 Departmental determination of
initial or continuing eligibility for
program benefits, including whether
benefits have been or are being paid
improperly; whether dual benefits
prohibited under any federal or state
law are being paid; and including salary
offset and debt collection procedures,
including any action required by the
Debt Collection Act of 1982.
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 such
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.
Note: Disclosure of information
contained in the file to a claimant or a
person who is duly authorized to act on
the claimant’s or beneficiary’s behalf
may be made over the telephone.
Disclosure over the telephone will only
be done where the requestor provides
appropriate identifying information to
OWCP personnel. Telephonic disclosure
of information is essential to allow
OWCP to efficiently perform its
functions in adjudicating and servicing
claims.
DISCLOSURE TO CONSUMER REPORTING
AGENCIES:

The amount, status and history of
overdue debts; the name and address,
taxpayer identification (SSAN), and
other information necessary to establish
the identity of a debtor, the agency and

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Federal Register / Vol. 81, No. 83 / Friday, April 29, 2016 / Notices
program under which the claim arose,
are disclosed pursuant to 5 U.S.C.
552a(b)(12) to consumer reporting
agencies as defined by the Fair Credit
Reporting Act (15 U.S.C. 1681a(f), or in
accordance with the Federal Claims
Collection Act of 1966 as amended (31
U.S.C. 3711(e) 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:

Files are stored electronically and/or
on paper.
RETRIEVABILITY:

Files are retrieved by coal miner’s
name, social security number, and
claimant’s social security number
different from miner’s.

DOL/OWCP–3

SAFEGUARDS:

Accessed by authorized personnel
only. Computer security safeguards are
used for electronically stored data and
locked locations for paper files.
Records are retained for 10 years after
death of last beneficiary. Denied claims
are retained for 30 years after final
denial in accordance with the
appropriate Records Schedule.
SYSTEM MANAGER(S) AND ADDRESS:

Director, Division of Coal Mine
Workers’ Compensation, Department of
Labor Building, Room C–3520, 200
Constitution Avenue NW., Washington,
DC 20210, and district office directors
(see ADDRESSES in the Appendix to this
document).
NOTIFICATION PROCEDURE:

Inquiries should be mailed to the
System Manager or submitted in such
other manner as directed by OWCP.
RECORD ACCESS PROCEDURE:

A request for access should be mailed
to the System Manager or submitted in
such other manner as directed by
OWCP.
CONTESTING RECORD PROCEDURES:

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A petition for amendment should be
mailed to the System Manager or
submitted in such other manner as
directed by OWCP.
RECORD SOURCE CATEGORIES:

Information contained in this system
is obtained from individuals,
organizations, and investigators.
SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS
OF THE ACT:

In accordance with 5 U.S.C.
552a(k)(2), investigatory material in this

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SYSTEM NAME:

Office of Workers’ Compensation
Programs, Longshore and Harbor
Workers’ Compensation Act Case Files.
SECURITY CLASSIFICATION:

RETENTION AND DISPOSAL:

VerDate Sep<11>2014

system of records compiled for law
enforcement purposes is exempt from
subsections (c)(3); (d); (e)(1); (e)(4)(G),
(H), and (I); and (f) of 5 U.S.C. 552a,
provided however, that if any
individual is denied any right, privilege,
or benefit that he or she would
otherwise be entitled to by Federal law,
or for which he or she would otherwise
be eligible, as a result of the
maintenance of these records, such
material shall be provided to the
individual, except to the extent that the
disclosure of such material would reveal
the identity of a source who furnished
information to the Government under an
express promise that the identity of the
source would be held in confidence, or
prior to January 1, 1975, under an
implied promise that the identity of the
source would be held in confidence.

Jkt 238001

None.
SYSTEM LOCATION:

Division of Longshore and Harbor
Workers’ Compensation, Office of
Workers’ Compensation Programs,
Washington, DC 20210, and district
offices of the Office of Workers’
Compensation Programs set forth in the
Appendix to this document.
CATEGORIES OF INDIVIDUALS COVERED BY THE
SYSTEM:

Employees injured or killed while
working in private industry who are
covered by the provisions of the
Longshore and Harbor Workers’
Compensation Act, the NonAppropriated Fund Instrumentalities
Act, the Defense Base Act, the War
Hazards Act, the Outer Continental
Shelf Lands Act, and the DC Workers’
Compensation Act, referred to
collectively herein as the Longshore and
Harbor Workers’ Compensation Act
(LHWCA).
CATEGORIES OF RECORDS IN THE SYSTEM:

This system may contain the
following kinds of records: Reports of
injury by the employee and/or
employer; claim forms filed by or on
behalf of injured employees covered
under the LHWCA or their survivors
seeking benefits under the LHWCA;
forms authorizing medical care and
treatment; other medical records and
reports; bills and other payments
records; compensation payments
records (including section 8(f) payment

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records); section 8(f) applications filed
by the employer; compensation orders
for or against the payment of benefits;
transcripts of hearings and depositions
conducted; and any other medical
employer or personal information
submitted or gathered in connection
with the claim. The system may also
contain information relating to dates of
birth, marriage, divorce, and death,
notes of telephone conversations
conducted in connection with the claim;
emails; information relating to
vocational and/or medical rehabilitation
plans and progress reports including
communication with rehabilitation
counselors, potential employers,
physicians and others who have been
contacted as part of the rehabilitation
process, notes created by the
rehabilitation specialist and the
rehabilitation counselor concerning the
rehabilitation process, vocational
testing, and other records pertaining to
the vocational rehabilitation process;
records relating to court proceedings,
insurance, banking, and employment;
articles from newspapers and other
publications; information relating to
other benefits (financial and otherwise)
the claimant or employer may be
entitled to; and information received
from various investigative agencies
concerning possible violations of
Federal civil or criminal law.
AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

33 U.S.C. 901 et seq. (20 CFR parts
701 et seq.); 36 DC Code 501 et seq.; 42
U.S.C. 1651 et seq.; 43 U.S.C. 1331 et
seq.; 5 U.S.C. 8171 et seq.
PURPOSE(S):

To maintain records on the actions of
insurance carriers, employers, and
injured workers with respect to injuries
reported under the Longshore and
Harbor Workers’ Compensation Act and
related Acts, to ensure that eligible
claimants receive appropriate benefits
as provided by the Act.
ROUTINE USES OF RECORDS MAINTAINED IN THE
SYSTEM, INCLUDING CATEGORIES OF USERS AND
THE PURPOSES OF SUCH USES:

In addition to those universal routine
uses listed in the General Prefatory
Statement to this document, disclosure
of information from this system of
records may also be made to the
following individuals and entities for
the purposes noted when the purpose of
the disclosure is compatible with the
purpose for which the information was
collected:
a. The employer or its representatives,
including third-party administrators,
and/or any party providing the
employer with workers’ compensation

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File TitleDOL Privacy Act systems updated 04-29-2016.pdf
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File Created2017-02-22

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