Ee-17a Claim For Home Health Care, Nursing Home, Or Assisted Li

CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR
ASSISTED LIVING BENEFITS UNDER THE ENERGY
EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION
PROGRAM ACT

U.S. Department of Labor

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Illness Compensation

Instructions

To claim for home health care, nursing home or assisted living benefits, please indicate below
which benefits you are claiming, provide the requested contact information for your treating
physician, sign and date the bottom of this form and mail it to: U.S. Department of Labor,
OWCP/DEEOIC, P.O. Box 34930, San Antonio, TX 78265. DO NOT WRITE IN SHADED AREAS.

Employee’s Information
Name (Last, First, Middle Initial)

OMB Control No: 1240-0002
Expiration Date: 03/31/2022

Social Security Number:
XXX-XX- _ _ _ _

Address (Street, Apt. #, P.O. Box)

DEEOIC Case ID#:

(City, State, Zip Code)

Telephone Number(s)
Home: (
)
Other: (

Type of Medical Benefit Claimed (Check appropriate box)

)

-

I hereby request Home Health Care, Nursing Home, or Assisted Living benefits that are directly related to my DEEOIC accepted
condition(s) and ordered by my treating physician. I acknowledge it is my responsibility to ensure that all requested medical
documentation is submitted in support of my claim for these benefits.

Home Health Care

Assisted Living

Nursing Home

Treating Physician of Record
Physician Name (Last, First, Middle Initial)

Telephone Number(s):
Office: (
)

Address (Name of Facility, Street, Suite #, P.O. Box)

Other: (

)

-

Note: Your physician must be either an M.D. or D.O.

(City, State, Zip Code)

Employee Declaration
Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to obtain
benefits provided under EEOICPA, or who knowingly accepts benefits to which that person is not entitled, is subject to civil or
administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a
fine, imprisonment, or both. Any change to the information provided on this form, once it is submitted, must be reported
immediately to the district office responsible for the administration of the claim. I hereby make a claim for benefits under
EEOICPA and affirm that the information I have provided on this form is true. I authorize any physician or hospital (or any other
person, institution, corporation or government agency) to furnish any desired information to the U.S. Department of Labor,
Office of Workers’ Compensation Programs.

__________________________________________________________
Employee Signature

Page 1

______________
Date

Form EE-17A
January 2015

Privacy Act Statement
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that: (1) The Energy Employees
Occupational Illness Compensation Program Act (42 USC 7384 et seq.) (EEOICPA) is administered by the Office of Workers’ Compensation
Programs of the U.S. Department of Labor, which receives and maintains personal information on claimants and their immediate
families. (2) Information received will be used to determine eligibility for, and the amount of, benefits payable under EEOICPA, and may
be verified through computer matches or other appropriate means. (3) Information may be disclosed to physicians and other health
care providers for use in providing treatment, performing evaluations for the Office of Workers’ Compensation Programs, and for other
purposes related to the medical management of the claim. (4) Information may be given to Federal, state, and local agencies for law
enforcement purposes, to obtain information relevant to a decision under EEOICPA, to determine whether benefits are being paid
properly, including whether prohibited payments have been made, and, where appropriate, to pursue debt collection actions required or
permitted by the Debt Collection Act. (5) Failure to disclose all requested information may delay the processing of the claim or the
payment of benefits, or may result in an unfavorable decision.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to the information collections on this form
unless it displays a 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 the data needed, and
completing and reviewing the collection of information. You are required to respond to this collection to obtain EEOICPA benefits (20
CFR 30.403). 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 S3524, 200 Constitution
Avenue N.W., Washington, D.C. 20210, and reference OMB Control No. 1240-0002 and Form EE-17A. DO NOT SUBMIT THE
COMPLETED FORM TO THIS ADDRESS.

Page 2

Form EE-17A
January 2015