Attachment 16 Equipment Supplement.doc

Ergonomic Equipment Medical Supplement

Date: _____________________ Your Physician’s Name: ________________________ Their Address : _________________________ Regarding:

Employee name: ___________________________

Employee DOB: ___________________________

Type of ergonomic equipment requested: __________________________ Dear Doctor, I have been asked to provide a medical opinion regarding the need for your patient to be authorized specialized ergonomic equipment different than the standard ergonomic equipment provided to our associates.

In order to determine if this person can be assigned specialized ergonomic equipment, we will need the following additional information:

· A copy of the last 6 months of the patient’s medical records (which relate to the patient’s need for specialized ergonomic equipment).

· A copy of any reports (which relate to the patient’s need for specialized ergonomic equipment) such as x-ray, MRI, lab work, etc. done in the last year.

I would like to talk with you about this request for specialized ergonomic equipment. Please let us know if there are times you are not available.

If you have any questions, please call 614-692-7145 or fax 614-692-4816.

Thank you, Physician’s Name

Defense Supply Center Columbus

Medical Services Provider

I request information be provided to the DSCC Medical Services Providers and for my physician to discuss (with the DSCC Medical Personnel), information to assist in making this determination.

Employee signature

Date

Privacy Act Statement: Authority: 5 U.S.C., Chapter 3 Purpose(s): Data is also used to manage ergonomics program.

Routine uses of records maintained in the system, including categories of users and the purposes of such uses: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therin may specifically be disclosed outside the DOD as a routine use pursuant to 5 U.S.C. 552a(b)3 as follows: The DOD ‘Blanket Routine Uses’ set forth at the beginning of DLA’s compilation of systems of records notices apply to this system.

Disclosure is Voluntary. However, without the information we cannot authorize you specialized ergonomic equipment.

ATTACHMENT 16