37.204—Procedure for obtaining payment.
Every claim for payment under this subpart shall be submitted to ALFORD and shall include:
(a)
An invoice (in duplicate) on the pathologist's letterhead or billhead indicating the date of autopsy, the amount of the claim and a signed statement that the pathologist is not receiving any other specific compensation for the autopsy from the miner's widow, his surviving next-of-kin, the estate of the miner, or any other source.
(b)
Completed PHS Consent, Release and History Form (See Fig. 1). This form may be completed with the assistance of the pathologist, attending physician, family physician, or any other responsible person who can provide reliable information.
(2)
Clinical abstract of terminal illness and other data that the pathologist determines is relevant.
(3)
Final summary, including final anatomical diagnoses, indicating presence or absence of simple and complicated pneumoconiosis, and correlation with clinical history if indicated.
Figure 1
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service—National Coal Workers' Autopsy Study
Consent, Release, and History Form Federal Coal Mine Health and Safety Act of 1969
I, _________, (Name) ______ (Relationship) of _________, (Name of deceased miner) do hereby authorize the performance of an autopsy (_________) (Limitation, if any, on autopsy) on said deceased. I understand that the report and certain tissues as necessary will be released to the United States Public Health Service and to _________ (Name of Physician securing autopsy)
I understand that any claims in regard to the deceased for which I may sign a general release of medical information will result in the release of the information from the Public Health Service. I further understand that I shall not make any payment for the autopsy.
Occupational and Medical History
1. Date of Birth of Deceased ______. (Month, Day, Year)
2. Social Security Number of Deceased _________.
3. Date and Place of Death ______, (Month, Day, Year) _________ (City, County, State).
4. Place of Last Mining Employment:
Name of Mine
Name of Mining Company
Mine Address
5. Last Job Title at Mine of Last Employment
(e.g., Continuous Miner Operator, motorman, foreman, etc.)
6. Job Title of Principal Mining Occupation (that job to which miner devoted the most number of years)
(e.g., Same as above)
7. Smoking History of Miner:
(a) Did he ever smoke cigarettes? Yes
No
(b) If yes, for how many years?______
Years.
(c) If yes, how many cigarettes per day did he smoke on the average?________
(Number of)
Cigarettes per day.
(d) Did he smoke cigarettes up until the time of his death? Yes ___ No ___
(e) If no to (d), for how long before he died had he not been smoking cigarettes?
8. Total Years in Surface and Underground Employment in Coal Mining, by State (If known) ___, (Years) ______ (State).
9. Total Years in Underground Coal Mining Employment, by State (If known) ___, (Years) ______ (State).
(Signature)
(Address)
(Date)
Interviewer: