Patient Background:

Name: ___________

Age: ___________

Sex: M/F

Years with P.O.:  _______

Other Relevant Facts:  ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dear Dr.:____________________________

The patient is a letter carrier working for the US Postal Service. The below listed job description is a requirement for the position. What the patient needs from you is, based on your diagnosis and findings, your medical opinion as to whether the patient’s condition is causally job related.

The Office of Workers’ Compensation Programs (OWCP,) defines an occupational disease or illness as an illness or disease produced by: systemic infections; continued or repeated stress or strain; exposures to toxins, poisons, fumes, etc: or other continued and repeated exposure to the work environment over a period of greater than a single shift or day.

An employee has a burden of proving that the disability claimed is causally related to an injury sustained in the performance of duty or, if an occupational disease, to the environment. The OWCP will not accept an occupational injury as job caused unless the patient and the patient’s physician can establish that the patient’s condition was caused by, aggravated by, or precipitated by factors in the patient’s employment.

Please summarize your findings showing a causal relationship between the patient’s condition and the job requirements, if any by addressing the following:

    1) Clarification of the “causal” relationship of the patient’s medical condition with his/her’ employment.

    2) Was the patients’ condition aggravated, accelerated, precipitated, or caused by his/her employment?

    3) Please rationalize #1 and #2 based on medical rational.

Please refer to the detailed job description of the Patient’s duties as a letter carrier which is described on the following pages.

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