CWHSP 2.19, Dec 20 Authorization for Payment of Autopsy

FOR NIOSH USE ONLY

Authorization for Payment of Autopsy

Form Approved—CDC/NIOSH
OMB Control No. 0920-0020
Exp

National Institute for Occupational Safety and Health
Deceased Miner’s Name (Last, First, Middle)
Sex

Social Security Number1 (Last 4 digits are required)

Date of Birth (MM/DD/YYYY)

Date of Death (MM/DD/YYYY)

/ /

Place of Death (City, State)

/ /

Miner’s next of kin (Last, First)

Relationship

City

State

Zip Code

Telephone Number

PARENCHYMAL ABNOMALITIES CONSISTENT WITH PNEUMOCONIOSIS (IF KNOWN)

Small Opacities
Yes
No

Areas

Profusion

Pneumoconiosis determination based upon
(Select all that apply): X-ray CT

Large Opacities
Yes
No

0/-

0/0

0/1

1/0

1/1

1/2

Upper

2/1

2/2

2/3

Middle

Was miner the victim of a coal mine disaster?

Lower

Yes

3/2

3/3

Zones Right Left

3/+

No

REQUESTING PATHOLOGIST INFORMATION

Physician’s name (Last, First, Middle)

Date of Birth (MM/DD/YYYY)

FEIN or SSN2

Hospital or Department

/ /

Street Address

City

State

Telephone Number

Zip Code

Email Address
Specialty

Active State License(s)
State:

License#

Primary

Board Certified? Yes

No

State:

License#

Secondary

Board Certified? Yes

No

I am requesting prior authorization and have proposed a payment amount to perform an autopsy on the above listed miner in accordance with 42 CFR 37 SUBPART–Autopsies.

Physician Signature (required for processing)

Date (MM/DD/YYYY)

/ /

PAYMENT INFORMATION

Proposed Payment Amount for Autopsy

Make payable to (First, MI, Last Name or Facility)

Mail payment to (Hospital or Department)

Street Address
State

City

Zip Code

Return completed form by secured track-able mail or fax:
Mail to: NIOSH Coal Workers’ Health Surveillance Program, 1000 Frederick Lane, Morgantown, WV 26508 Fax: 1-304-285-6058
FOR NIOSH USE ONLY

NIOSH Official Authorizing Payment (First, Last)

Title

Signature

Date (MM/DD/YYYY)

/ /

Social Security Number (SSN) is requested solely for identification and for payment. It will be treated as confidential information and released only with permission of the requesting pathologist.
Federal Employer Identification Number (FEIN) or Social Security Number (SSN).

1
2

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer; 1600 Clifton Road NE, MS E-11, Atlanta,
Georgia 30329; ATTN: PRA (0920-0020). Do not send completed form to this address.

CWHSP 2.19, Dec 2020, CS310505

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