Social Security Number:

U.S. Department of Labor 

Office of Workers’ Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

CLAIM FOR HOME HEALTH CARE, NURSING HOME, OR 

ASSISTED LIVING BENEFITS UNDER THE ENERGY 

EMPLOYEES OCCUPATIONAL ILLNESS COMPENSATION

PROGRAM ACT

OMB Control No. 1240-0002 

Expiration Date: 05/31/2025

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 8306, London, KY 

40742-8306. DO NOT WRITE IN SHADED AREAS.

Name (Last, First, Middle Initial)

(City, State, Zip Code) Telephone Number(s)

Type of Medical Benefit Claimed (Check appropriate box) 

Form EE-17A 

Page 1 September 2021

XXX-XXEmployee’s Information

Instructions

DEEOIC Case ID#:

Home:

Other:

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)

(City, State, Zip Code)

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

Telephone Number(s):

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

Office:

Other:

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 Date

Address (Street, Apt. #, P.O. Box)
Form EE-17A

Page 2 September 2021

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.

Privacy Act 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.

Public Burden Statement