Dol/esa-49 (eeoicpa)

DOL ESA-49 (EEOICPA).docx

Medical Travel Refund Request

DOL/ESA-49 (EEOICPA)

OMB: 1240-0037

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Privacy Act Systems - DOL/ESA-49

SYSTEM NAME:

    Office of Workers' Compensation Programs, Energy Employees Occupational Illness Compensation Program Act File.

SECURITY CLASSIFICATION:

    Most files and data are unclassified. Files and data in certain cases have Top Secret classification, but the rules concerning their maintenance and disclosure are determined by the agency that has given the information the security classification of Top Secret.

SYSTEM LOCATION:

    U.S. Department of Labor, Employment Standards Administration, Office of Workers' Compensation Programs, Frances Perkins Building, 200 Constitution Ave., NW, Washington, DC 20210, and district offices located throughout the United States.

CATEGORIES OF INDIVIDUALS COVERED BY THE SYSTEM:

    Individuals or their survivors who claim benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). These individuals include, but are not limited to, federal employees or survivors of federal employees; employees or survivors of employees of the Department of Energy, its predecessor agencies, and their contractors and subcontractors; and members of the armed forces.

CATEGORIES OF RECORDS IN THE SYSTEM:

    This system may contain the following kinds of records: claim forms filed by or on behalf of injured individuals or their survivors seeking benefits under the EEOICPA; reports by the employee and/or the U.S. Department of Energy; employment records; exposure records; safety records or other incident reports; dose reconstruction records; workers' or family members contemporaneous diaries, journals, or other notes; forms authorizing medical care and treatment; other medical records and reports; bills and other payment records; compensation payment records; formal orders for or against the payment of benefits; transcripts of hearings conducted; and any other medical, employment, or personal information submitted or gathered in connection with the claim. The system may also contain information relating to dates of birth, marriage, divorce, and death; notes of telephone conversations conducted in connection with the claim; information relating to vocational and/or medical rehabilitation plans and progress reports; records relating to court proceedings, insurance, banking and employment; articles from newspapers and other publications; information relating to other benefits (financial and otherwise) the claimant may be entitled to, including previously filed claims; and information received from various investigative agencies concerning possible violations of Federal civil or criminal law.

    The system may also contain consumer credit reports on individuals indebted to the United States, information relating to the debtor's assets, liabilities, income and expenses, personal financial statements, correspondence to and from the debtor, information relating to the location of the debtor, and other records and reports relating to the implementation of the Federal Claims Collection Act (as amended), including investigative reports or administrative review matters. Individual records listed here are included in a claim file only insofar as they may be pertinent or applicable to the individual claiming benefits.

AUTHORITY FOR MAINTENANCE OF THE SYSTEM:

    Energy Employees Occupational Illness Compensation Program Act, Title XXXVI of Pub. L. 106-398, October 30, 2000, 114 Stat. 1654.

PURPOSE(S):

    To maintain records on individuals who file claims under the Energy Employees Occupational Illness Compensation Program Act, which establishes a program for compensating certain individuals for covered illnesses related to exposure to beryllium, cancers related to exposure to radiation, and chronic silicosis. These records provide information and verification about individual claimants' covered illnesses on which may be based any entitlement to medical treatment, compensation and survivors' benefits, under the EEOICPA and certain other statutes.

ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM, INCLUDING CATEGORIES OF USERS AND THE PURPOSE OF SUCH USES:

    In addition to those Department-wide routine uses set forth above in the General Prefatory Statement to this document, disclosure of information from this system of records may be made to the following individuals and entities for the purposes noted when the purpose of the disclosure is both relevant and necessary and is compatible with the purpose for which the information was collected:

  1. To any attorney or other representative of an EEOICPA beneficiary for the purpose of assisting in a claim or litigation against a third party or parties potentially liable to pay damages as a result of the beneficiary's compensable condition, and for the purpose of administering the provisions of §§ 3641-3642 of the EEOICPA. Any such third party, or a representative acting on that third party's behalf, may be provided information or documents concerning the existence of a record and the amount and nature of compensation paid to or on behalf of the beneficiary for the purpose of assisting in the resolution of the claim or litigation against that party or administering the provisions of §§ 3641-3642 of the EEOICPA.

  2. To the Department of Energy, its contractors and subcontractors, and federal agencies that employed the employee at the time of the alleged exposure of the employee, and to other entities that may possess relevant information, to assist in administering the EEOICPA, to answer questions about the status of the claim, to consider other actions the agency may be required to take with regard to the claim, or to permit the agency to evaluate its safety and health program. Disclosure to federal agencies, including the Department of Justice, may be made where OWCP determines that such disclosure is relevant and necessary for the purpose of providing assistance in regard to asserting a defense based upon the EEOICPA's exclusive remedy provision to an administrative claim or to litigation filed under the Federal Tort Claims Act.

  3. To the personnel, contractors, grantees, and cooperative agreement holders of the Department of Energy, the Department of Health and Human Services, the Department of Justice, and other federal agencies designated by the President to implement the federal compensation program established by the EEOICPA, for the purpose of assisting in the adjudication or processing of a claim under that Act.

  4. To physicians, pharmacies, and other health care providers for their use in treating the claimant, in conducting an examination or preparing an evaluation on behalf of OWCP and for other purposes relating to the medical management of the claim, including evaluation of and payment for charges for medical and related services and supplies.

  5. To medical insurance or health and welfare plans (or their designees) that cover the claimant in instances where OWCP had paid for treatment of a medical condition that is not compensable under the EEOICPA, or where a medical insurance plan or health and welfare plan has paid for treatment of a medical condition that may be compensable under the EEOICPA, for the purpose of resolving the appropriate source of payment in such circumstances.

  6. To a federal, state or local agency for the purpose of obtaining information relevant to a determination concerning initial or continuing eligibility for EEOICPA benefits, and for a determination concerning whether benefits have been or are being properly paid, including whether dual benefits that are prohibited under any applicable federal or state statute are being paid; and for the purpose of utilizing salary offset and debt collection procedures, including those actions required by the Debt Collection Act of 1982, to collect debts arising as a result of overpayments of EEOICPA compensation and debts otherwise related to the payment of EEOICPA benefits.

  7. To the Internal Revenue Service (IRS) for the purpose of obtaining taxpayer mailing addresses for the purposes of locating a taxpayer to collect, compromise, or write-off a federal claim against such taxpayer; and informing the IRS of the discharge of a debt owed by an individual. Records from this system of records may be disclosed to the IRS for the purpose of offsetting a federal claim from any income tax refund that may be due to the debtor.

  8. Where an investigation, settlement of claims, or the preparation and conduct of litigation is undertaken, a record may be disclosed to (1) a person representing the United States or the Department of Labor in the investigation, settlement or litigation, and to individuals assisting in such representation; (2) others involved in the investigation, settlement, and litigation, and their representatives and assistants; and (3) a witness, potential witness, or their representatives and assistants, and to any other person who possesses information pertaining to the matter, when such disclosure is necessary for the conduct of the investigation, settlement, or litigation, or is necessary to obtain information or testimony relevant to the matter.

  9. To the Defense Manpower Data Center - Department of Defense and the United States Postal Service to conduct computer matching programs for the purpose of identifying and locating individuals who are receiving Federal salaries or benefit payments and are delinquent in their repayment of debts owed to the United States under programs administered by the DOL in order to collect the debts under the provisions of the Debt Collection Act of 1982 (Pub. L. 97-365) by voluntary repayment, or by salary or administrative offset procedures.

  10. To a credit bureau for the purpose of obtaining consumer credit reports identifying the assets, liabilities, expenses, and income of a debtor in order to ascertain the debtor's ability to repay a debt incurred under the FECA, to collect the debt, or to establish a payment schedule.

  11. The amount, status and history of overdue debts, the name and address, taxpayer identification (SSN), and other information necessary to establish the identity of a debtor, the agency and program under which the claim arose, may be disclosed pursuant to 5 U.S.C. 552a(b)(12) to consumer reporting agencies as defined by section 603(f) of the Fair Credit Reporting Act (15 U.S.C. 1681a(f)) or in accordance with section 3(d)(4)(A)(ii) of the Federal Claims Collection Act of 1966 as amended (31 U.S.C. 3711(f)) for the purpose of encouraging the repayment of an overdue debt.

  12. To individuals, and their attorneys and other representatives, and government agencies, seeking to enforce a legal obligation on behalf of such individual or agency, to pay alimony and/or child support for the purpose of enforcing such an obligation, pursuant to an order of a state or local court of competent jurisdiction, including Indian tribal courts, within any State, territory or possession of the United States, or the District of Columbia or to an order of a State agency authorized to issue income withholding notices pursuant to State or local law or pursuant to the requirements of section 666(b) of title 42, United States Code, or for the purpose of denying the existence of funds subject to such legal obligation.

  13. To the spouse, children, parents, grandchildren, or grandparents of deceased employees who may be covered under the EEOICPA to enable them to determine their eligibility for benefits under the EEOICPA, and to inform them of decisions regarding benefit eligibility, so that they have the opportunity to take action to protect any rights they may have as potentially eligible beneficiaries.

    Note: Disclosure of information contained in this system of records to the subject of the record, a person who is duly authorized to act on his or her behalf, or to others to whom disclosure is authorized by these routine uses, may be made over the telephone or by electronic means. Disclosure over the telephone or by electronic means will only be done where the requestor provides appropriate identifying information. Telephonic or electronic disclosure of information is essential to permit efficient administration and adjudication of claims under the EEOICPA.

DISCLOSURE TO CONSUMER REPORTING AGENCIES:

    The amount, status and history of overdue debts, the name and address, taxpayer identification (SSAN), and other information necessary to establish the identity of a debtor, the agency and program under which the claim arose, may be disclosed pursuant to 5 U.S.C. 552a(b)(12) to consumer reporting agencies as defined by section 603(f) of the Fair Credit Reporting Act (15 U.S.C. 1681a(f)) or in accordance with section 3(d)(4)(A)(ii) of the Federal Claims Collection Act of 1966 as amended (31 U.S.C. 3711(f)) for the purpose of encouraging the repayment of an overdue debt.

POLICIES AND PRACTICES FOR STORING, RETRIEVING, ACCESSING, RETAINING AND DISPOSING OF RECORDS IN THE SYSTEM:

STORAGE:

    Paper case files are maintained in filing cabinets. Automated data, including case files that have been transformed into electronic form, are stored in computer discs or magnetic tapes, which are stored in cabinets. Microfiche is stored in cabinets.

RETRIEVABILITY:

    Files and automated data are retrieved after identification by coded file number and/or Social Security Number which is cross-referenced to employee by name, employer and/or contractor, and date and nature of injury.

SAFEGUARDS:

    Files and automated data are maintained under supervision of OWCP personnel during normal working hours - only authorized personnel, with the appropriate password, may handle, retrieve, or disclose any information contained therein. Access to electronic records is controlled by password or other user identification code.

RETENTION AND DISPOSAL:

    All case files and automated data pertaining to a claim are destroyed 15 years after the case file has become inactive. Paper files that have been scanned to create electronic copies are destroyed after the copies are verified. Automated data is retained in its most current form only, however, and as information is updated, outdated information is deleted. Some related financial records are retained only in electronic form, and destroyed 6 years and 3 months after creation or receipt.

SYSTEM MANAGER(S) AND ADDRESS:

    Director, Office of Workers' Compensation Programs, 200 Constitution Avenue, NW, Washington, DC 20210.

NOTIFICATION PROCEDURES:

    An individual wishing to inquire whether this system of records contains information about him/her may write or telephone the OWCP district office that services the state in which the individual resided or worked at the time he or she believes a claim was filed. In order for the record to be located, the individual must provide his or her full name, OWCP claim number (if known), date of injury (if known), and date of birth.

RECORD ACCESS PROCEDURES:

    Any individual seeking access to non-exempt information about a case in which he/she is a party in interest may write or telephone the OWCP district office where the case is located, or the systems manager.

CONTESTING RECORD PROCEDURES:

    Any individual requesting amendment of non-exempt records should contact the appropriate OWCP district office, or the system manager. Individuals requesting amendment of records must comply with the Department's Privacy Act regulations at 29 CFR 71.1 and 71.9.

RECORD SOURCE CATEGORIES:

    Injured employees who are the subjects of the record, their family members and beneficiaries; employing Federal agencies; State governments, State agencies, and other Federal agencies; State and Federal workers' compensation offices; physicians and other medical professionals; hospitals; clinics; medical laboratories; suppliers of health care products and services and their agents and representatives; educational institutions; attorneys; Members of Congress; OWCP field investigations; consumer credit reports; investigative reports; correspondence with the debtor including personal financial statements; records relating to hearings on the debt; and other DOL systems of records.

SYSTEMS EXEMPTED FROM CERTAIN PROVISIONS OF THE ACT:

    In accordance with 5 U.S.C. 552a(k)(2), investigative material in this system of records compiled for law enforcement purposes is exempt from subsections (c)(3), (d), (e)(1), (e)(4)(G), (H) and (I), and (f) of 5 U.S.C. 552a, provided, however, that if any individual is denied any right, privilege, or benefit that he or she would otherwise be entitled to by Federal law, or for which he or she would otherwise be eligible, as a result of the maintenance of these records, such material shall be provided to the individual, except to the extent that the disclosure of the material would reveal the identity of a source who furnished information to the Government under an express promise that the identity of the source would be held in confidence, or prior to January 1, 1975, under an implied promise that the identity of the source would be held in confidence.



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