File Number: «CaseNumber»
«FORM»-«CAT»-«SUBJ»
OMB No: 1240-0046
Expiration Date: XX-XX-XXXX
U.S. DEPARTMENT OF LABOR
«SenderAddress»
Phone: «SenderPhone»
Date of Injury: «DtInjury»
Employee: «ClaimantFullName»
«ToAddress»
Dear «Salutation»:
Because of your expertise, we are referring «ClaimantFullName» to you for audiologic and otologic evaluation. Since this is for the adjudication of a compensation claim, there are many specific points that are legally required. They are spelled out in the enclosed instruction, CA1087 and its attachments. In order to make these easier to complete, the enclosed outline was developed. If you complete the outline as specified, you will have automatically met all of the legal requirements for adjudication and payment. We have enclosed copies of pertinent information form the case file including all available medical reports, audiograms, and noise exposure data.
This claim must be judged on the basis of the Statement of Accepted Facts. If the Statement of Accepted Facts is at variance with the history as given by the patient, please contact us as we will check for errors and either verify or amend the Statement of Accepted Facts. The Statement of Accepted Facts must, however, be the only background against which the claim is evaluated.
If your staff or equipment do not meet the specifications in the outline (taken from the enclosed CA1087), or if you need special tests such as ABER studies, for which you may not have the equipment, please sent the patient out for the necessary audiometry.
If a patient obstructs the examination or fails to give you full cooperation in obtaining legitimate thresholds, or if you have reservations as to the audiometric studies, find them inadequate, or perceive indications of potential malingering, please report and document that concern/reservation and arrange for retesting and/or additional testing as required. Any special studies required to attempt to resolve such questions, such as ABERS, are approved for payment.
No part of the case file, the medical findings or your report is to be made available to anyone other than those professional individuals directly involved in this evaluation. Also, no material related to your examination is to be used for teaching purposes or abstracted for publication without the prior approval of this Office.
To ensure timely payment for your services, please use the enclosed OWCP-1500 billing form with Prompt Payment Authorization Number «usr_PMT_AUTHORIZATION_NO».
The billing form must contain the tax identification number (SSN or EIN) in Block 25 and the provider's signature with date in Block 31. Payment will be made within 30 days of receipt of the medical report and completed OWCP-1500.
We are most grateful for your courtesy in assuming this work. The legitimate adjudication of this claim is dependent on your labors and integrity. If there are any questions, please contact me.
Sincerely,
«SignatureName»
«SignatureTitle»
«CCAddresses»
CA-1331 PAGE 2 (Rev. xx-xx)
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number.
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C 8101, et seq. 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, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to the address shown just above. Rather, send it to the address shown on the letterhead.
Privacy Act Statement
The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C. 8101, et seq.), authorizes collection of this information. The information will be used in conjunction with the Form CA-1332 to refer a claimant for complete audiologic and otologic examination when a claim for hearing loss has been filed. Completion of this form is voluntary, however, failure to provide the information may result in the delay of processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.
CA-1331 PAGE 3 (Rev. xx-xx)
OWCP HEARING LOSS MEDICAL REQUIREMENTS
Each employee should be seen for audiological and otological examination. The audiological testing should precede the visit to the otologist; the otologist should have the audiological findings at the time of the examination; and, to the extent possible, these two consultations should occur on the same day. It is also required that the audiological and otological examinations be performed by different individuals.
Any tests administered as part of an audiological battery must be conducted by a person possessing certification in audiology from the American Speech-Language-Hearing Association (ASHA) or State licensure as an audiologist. The medical examination must be performed by an otolaryngologist certified (or eligible for certification) by the American Academy of Otolaryngology. All tests comprising the battery administered in the audiological evaluation must be performed in an environment meeting the specifications of ANSI S3.1 (1977). Facilities which are accredited by the Professional Service Board of the ASHA meet this requirement. Testing equipment must be calibrated in accordance with the protocol contained in the accreditation manual of ASHA's Professional Service Board (ANSO S3.6-1969).
Audiometric tests must include the following:
Pure-tone air conduction thresholds should be obtained for each ear at 500, 1000, 2000, 3000, 4000, 6000 and 8000 Hz. Bone conduction thresholds should be obtained for the specified frequencies from 500 to 4000 Hz, inclusive. Appropriate masking should be employed as necessary and the use of masking should be denoted on the audiogram. The symbols used in recording thresholds should be in accordance with the most recent ASHA recommendations.
Impedence audiometry should be done on both ears as a means of determining the reliability of determining the reliability of air-bone conduction threshold relationships and for any contribution it might otherwise make to differential diagnosis by the physician.
Speech reception thresholds for each ear should be established using test procedures and spondaic words which conform to guidelines (ASHA Committee on Audiometric Evaluation, 1979). Standardized recorded materials should be used rather than live voices.
Monaural discrimination scores should be obtained; masking should be used when necessary. Standardized recorded word lists should serve as the stimuli and the discrimination scores for the full list should be reported for each ear.
CA-1087 (Rev.xx-xx) OMB 1240-0046
Expires: XX-XX-XXXX
Reports must include, as appropriate:
Date and hour of examination.
Date and hour of employee's last exposure to loud noise. (If the employee was exposed to noise win the last 16 hours, do not proceed with testing.)
History of injury.
The physician's rationalized medical opinion regarding the relation of the hearing loss to employment-related noise exposure.
The physician's recommendation for treatment.
A certification must accompany each audiological battery indicating the instrument calibration and the environment in which the tests were conducted met the accreditation standards of the Professional Services Board of ASHA.
A statement commenting on the reliability of the tests.
CA-1087 PAGE 2 (Rev. xx-xx) OMB 1240-0046
Expiration Date: XX-XX-XXXX
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a currently valid OMB control number.
Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under 5 U.S.C 8101 et seq. 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, and reference the OMB Control Number 1240-0046. Note: Please do not return the requested information to the address shown just above. Rather, send it to the address shown on the letterhead.
Privacy Act Statement
The Privacy Act of 1974 as amended (5 U. S.C. 552a) and the Federal Employees’ Compensation Act, as amended and extended (5 U.S.C. 8101 et seq.), authorizes collection of this information. The information will be used in conjunction with the Form CA-1332 to refer a claimant for a complete audiological and otological examination when a claim for hearing loss has been filed. Completion of this form is voluntary, however, failure to provide the information may result in the delay of processing of the claim or payment or benefits, or may result in an unfavorable decision or reduced levels of benefits. Additional disclosures of this information may be to: third parties in litigation; employing agencies, various individuals and organizations providing related medical rehabilitation and other services; insurance plans which may have paid related bills; labor unions; various law enforcement officials; other federal, state and local agencies (including the GAO and IRS) as appropriate; data processing contractors to the Department of Labor; debt collection agencies and credit bureaus.”
CA-1087 PAGE 3 (Rev.xx-xx)
If you have a disability and are in need of communication assistance (such as alternate formats or sign language interpretation), accommodations and/or modifications, please contact OWCP.
| File Type | text/rtf |
| Author | ddove |
| Last Modified By | Sharpless, Marcus J - OWCP |
| File Modified | 2017-10-20 |
| File Created | 2017-10-20 |