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EE-17B Physician's Certification of Medical Necessity

After an energy employee files Form EE-17A to claim home health care, DEEOIC sends this certification to the treating physician. The physician confirms a recent face-to-face exam and either requests an in-home assessment by a home health provider or attaches a letter of medical necessity with a plan of care for home health, nursing home or assisted living services tied to the accepted conditions.

Who completes it

The treating physician completes the whole form and signs the declaration. A nurse practitioner or physician assistant cannot sign the letter of medical necessity, and their evaluations must be certified by a physician.

Submitting and payment

How to submit it
Mail it to the DEEOIC central mail room or upload it through the Energy Document Portal, which DEEOIC calls the quickest route.
Who pays
The form sets no fee, and its declaration notes that DEEOIC pays only for care medically necessary to treat accepted conditions.

Good to know

  • The letter of medical necessity must state that you personally examined the patient within the past 60 days and describe findings and functional limitations caused by the accepted illness.
  • For each type of care, such as skilled nursing, home health aide, respiratory therapy or OT/PT, give hours per day, days per week and the services each caregiver performs.
  • DEEOIC will not pay for care of a condition that may be a consequence of an accepted condition until that condition is claimed and accepted.
  • If you request an in-home assessment, DEEOIC authorizes the patient's chosen home health provider to assess, and the district office sends you the report before you write the letter.

Get the official form

Download the current version from the source each time; forms change without notice.

Physician's Certification of Medical Necessity under the Energy Employees Occupational Illness Compensation Program Act

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Can a nurse practitioner sign Form EE-17B?

No. The form notes that the letter of medical necessity cannot be signed by a nurse practitioner or physician assistant. Medical documentation must be signed by a physician, which DEEOIC defines to include surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors and osteopathic practitioners.

What should the EE-17B letter of medical necessity include?

A narrative of your physical findings from an exam within the past 60 days, the functional limitations caused solely by the accepted work-related illness, the types of home health care needed, the hours per day and days per week for each, and the specific services each type of caregiver will perform.

What happens after the physician returns EE-17B?

The home health agency requests prior authorization of the service plan on Form EE-32, attaching the letter of medical necessity, evidence of the face-to-face exam and the plan of care. If you asked for an in-home assessment instead, you receive the assessment report first and then prepare the letter.