EEOICPA Forms

Haven Home Health Care provides access to all forms EEOICPA care patients might need to complete in order to take full advantage of their reimbursement rights under the Energy Employees Occupational Illness Compensation Act (EEOICPA).  Simply click on the blue link that describes the form that you need, and it will be available to fill out online, or to print out and fill out manually.  If you choose to fill out the form online, please print and save a copy for your records.  Your Haven Home Health Care expert-trained EEOICPA staff member is available to help you with every aspect of EEOICPA forms completion.

List of DOL EEOICPA Forms

EEOICP EE-1

Worker’s Claim for Benefits Under the Energy Employees Occupational Illness Compensation Act. This form must be completed by all energy workers who want to claim eligibility for benefits under the EEOICPA.

EEOICP EE-2

Claim for Survivor Benefits Under the Energy Employees Occupational Illness Compensation Act.  This form must be completed by any survivor of an energy employees who wishes to claim eligibility for benefits under the EEOICPA.

EEOICP EE-3

Employment History for a Claim Under the Energy Employees Occupational Illness Compensation Act. This form must be completed by all energy workers or survivors of energy workers who wish to claim eligibility for benefits under the EEOICPA.

EEOICP EE-4

Employment History Affidavit for a Claim Under the Energy Employees Occupational Illness Compensation Act.  This form must be completed by all energy workers or survivors of energy workers who wish to claim eligibility for benefits under the EEOICPA.

EEOICP EE-7

Medical Requirements under the Energy Employees Occupational Illness Compensation Program Act. This form identifies the Medical Requirements documentation required for submission of a claim under the Energy Employees Occupational Illness Compensation Program Act.

EEOICPA form OWCP-915

Claim for Medical Reimbursement under the Energy Employees Occupational Illness Compensation Act. This form is used to claim reimbursement for out-of-pocket medical expenses pertaining to the treatment of an accepted condition covered by the Federal Employees’ Compensation Act.

EEOICPA form OWCP-957

Medical Travel Refund Request.  This form is used to claim reimbursement for medically related travel covered by the Energy Employees Occupational Illness Compensation Act.

EEOICPA form OWCP-1500

Health Insurance Claim Form. Health Insurance Claim Form: This information is required to reimburse health care providers for services rendered to injured employees covered under the Energy Employees Occupational Illness Compensation Act. Each physician or clinic that provides EEOICPA beneficiaries with services must have and fill out one of these forms.

 

If you have any questions about any EEOICPA forms, how to complete those forms, or what the purpose of the form is, contact your Haven Home Health Care expert-trained staff member by clicking here for Haven HHC contact information or by calling the phone number you have been given by your Haven Home Health Care staff member.

For more information on EEOICPA care and benefits, you can click on the following links:

EEOICPA Frequently Asked Questions

EEOICPA: Haven Home Health Care Can Help