DCMWC sends this statement to a black lung beneficiary's physician when it must decide whether someone else should receive and manage the benefits as a representative payee. Based on an examination within the past year, the physician gives an opinion on whether the patient can manage benefit payments in their own interest and describes the findings, diagnosis and type of impairment behind that view.
The patient's physician or medical officer completes the statement and signs the certification. DOL fills in the identifying case information, and the patient does not complete any part.
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Physician's/Medical Officer's Statement
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A No answer means you believe the patient cannot manage benefit payments. You then complete items 2 to 5: findings, diagnosis, mental or physical impairment, onset date, last exam date, whether the inability will continue, and who looks after the patient. If DOL finds the patient incapable, it normally appoints a representative payee.
No. The form says you are not required to respond, but your cooperation helps DOL decide whether having the patient's funds managed by another party is in the patient's best interest. DOL weighs your answers together with other evidence it receives.
The instructions give examples such as severe intellectual disability present since birth, senility or forgetfulness from advancing age, schizophrenia and other mental health problems, and physical impairments so severe that the beneficiary cannot manage funds or direct others to manage them.