U.S. Department of Labor 

Office of Workers’ Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

PHYSICIAN’S CERTIFICATION OF MEDICAL 

NECESSITY UNDER THE ENERGY EMPLOYEES 

OCCUPATIONAL ILLNESS COMPENSATION 

PROGRAM ACT

OMB Control No. 1240-0002 

Expiration Date: 05/31/2025

Please provide the identifying information requested below, indicate the date of your face-to-face physical 

examination of your patient, check either the box requesting an in-home assessment or the other box indicating 

you are attaching a Letter of Medical Necessity, sign and date the bottom of this form. For additional 

instructions, see page 2. DO NOT WRITE IN SHADED AREAS.

Name (Last, First, Middle Initial)

(City, State, Zip Code)

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

Telephone Number(s)

Form EE-17B 

Page 1 September 2021

SSN: XXX-XXPatient Information

Instructions

DEEOIC Case I.D.:

Home: 

Other: 

Treating Physician Information

Physician Name (Last, First, Middle Initial)

(City, State, Zip Code)

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

Telephone Number(s):

Office:

Other:

Physician Declaration

By signing this Form EE-17B, I acknowledge that: the above-named patient is currently under my care for the DEEOIC accepted condition(s) 

listed above; I have personally examined this patient on the date indicated above; I have read the DEEOIC Home Health Care Letter to 

Physicians; I understand that DEEOIC only pays for care that is medically necessary for treatment of DEEOIC accepted conditions; and I 

understand that DEEOIC cannot pay for care for any condition that may be a consequence of DEEOIC accepted condition(s) until specifically 

claimed for and accepted by DEEOIC. I have attached copies of the relevant medical documentation and objective testing supporting my 

attached Letter of Medical Necessity (if I have provided one). 

Physician Signature Date

Date of Birth:

(Last Four Only)

National Provider 

Identifier:

Circle One: M.D. or D.O.

(

(

(

(

DEEOIC Accepted Conditions

Date of Physician’s Examination, and Request for Assessment or Letter of Medical Necessity (check appropriate box)

Date of Face-to-Face 

Physical Examination: In-home Assessment Requested

Letter of Medical Necessity Attached

Before prescribing home health care, nursing home or assisted living services for my patient, I am requesting an 

in-home assessment to assist me in determining the need for services related to the accepted condition(s) listed 

above.

I have attached a Letter of Medical Necessity that contains both a plan of care and the rationale for my 

conclusion that the prescribed home health care, nursing home or assisted living services are medically 

necessary for treatment of the accepted condition(s) listed above.
Form EE-17B 

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 healthcare 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.

Additional Instructions to Physician

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 30 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 not required to respond to this collection, but failure to respond may result in an unfavorable decision. 

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-17B. DO NOT SUBMIT THE COMPLETED FORM TO 

THIS ADDRESS.

Public Burden Statement

Privacy Act Statement

Form EE-17B is used to obtain a Letter of Medical Necessity (LMN) from the treating physician that describes the claimant’s Home Health 

Care (HHC) needs as they relate to one or more of the DEEOIC accepted conditions identified on this form. The LMN must state that you 

have personally met with and examined your patient within the past 60 days, and have made a determination as to the type of care, and 

the frequency and duration of such in-home care, as it relates to the accepted condition(s). 

If you feel that you need more information from your patient before you can prepare the LMN, you may first wish to schedule a visit with 

your patient to discuss his/her HHC needs. If you feel that an in-home assessment by a provider of HHC services would be of value, 

please check the appropriate box on page 1, sign the Physician Certification at the bottom of the form and return it to the DEEOIC Central 

Mail Room address below. Our claims staff will notify the HHC provider, designated by your patient, that an in-home assessment of HHC 

needs has been authorized by DEEOIC. Once the assessment has been completed, our district office will forward a report to your office, 

and you can proceed with preparing your LMN. Once you have the necessary information to prepare a LMN, here is the specific 

information we are seeking: 

Physical Examination: DEEOIC requires a physician to have personally visited with and conducted a physical examination of the 

patient, within the past 60 days. Your LMN should provide a written narrative describing your physical findings at the time of 

examination, and the specific functional limitations resulting exclusively from the accepted work-related illness. 

Type and Duration of Care: The LMN must clearly specify the type(s) of HHC required, and for each type of care must specify the 

number of hours per day, and number of days per week for that particular type of service. The letter must also provide a 

description of the specific medical services to be performed by each type of caregiver. Examples of the various types of HHC 

available are as follows: 

Skilled Nursing Care (RN/LPN) 

Home Health Aid/Personal Care Attendant 

Respiration Therapist 

Occupational/Physical Therapist 

Please be sure to sign the Form EE-17B and mail it to the claims examiner at: U.S. Department of Labor, OWCP/DEEOIC, P.O. Box 8306, 

London, KY 40742-8306.