Printing - FECA-PT2 - National Association of Letter Carriers

personal activities) which involve strenuous physical effort, travel, recent personal or family crisis
(divorce, illness or death of a loved one, substance abuse, etc.)
3. Describe your smoking history. Do you smoke? If so, how much and for how long? If you don't
smoke now, did you? How much, for how long, and when did you quit?
4. Describe the development of the claimed condition. When did you first experience cardiac
symptoms? Describe the progression. What treatment has been effective in relieving your symptoms?
What makes your condition worse?
5. Provide all details of previous cardiovascular problems, including all incidents of chest pain or
angina, heart attack(s), bypass surgery, etc. Have you ever been diagnosed as having coronary artery
disease, high blood pressure, or diabetes?
6. Provide medical records from all previous treatment for cardiac symptoms or a heart-related
condition.
7. Describe your activities before the onset of the claimed heart attack (or acute symptoms). What
were you doing just beforehand, during the previous 24 hours, and during the previous 72 hours?
8. Provide a detailed medical report from your treating physician which describes your symptoms;
results of examinations and tests; diagnosis; the treatment provided; the effect of treatment; and the
doctor's opinion, with medical reasons, on the cause of your condition. Specifically, if your doctor feels
that incidents in your Federal employment contributed to your condition, an explanation of how such
incidents contributed should be provided.
9. Provide the name, address and phone number of your attending physician(s).
10. Sign and return a medical release form for each physician or medical facility who has treated you
for the claimed condition. Two forms are enclosed for this purpose. This will enable us to correspond
directly with your physician(s) if additional information or clarification is necessary.
11. [FREE FLOW IF DESIRED]
We may write directly to a physician or any other party who may be able to provide information which will
help us decide your eligibility for benefits. Our efforts are intended to assist you in collecting evidence.
Please understand that it is ultimately your responsibility, as the claimant, to provide or ensure the
provision of all evidence needed to decide your claim. Whenever we request information, we will send you
a copy so you may ensure that the requested information is provided as soon as possible.
We are committed to making a timely decision on your claim. We will allow 30 days for the submission of
all requested evidence. If we have not received the requested information, an indication that it is
forthcoming, or evidence that the information is not necessary to decide your claim, we will render a
decision on your claim based on the evidence in file.
If you do not understand any part of this request, or you cannot provide all requested information for any
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