GUIDANCE FOR EVACUATED VOLUNTEERS

Post Service Health Benefits for COVID-19 Evacuees

Post Service Care What insurance do I have?

a. There are two types of insurance for RPCVs, Short-term Health Insurance for Transition and Travel (SHIFTT) and PC-127C/209B Authorizations for Evaluations. Both programs use the International Medical Group’s (IMG) First Health network.

i. SHIFTT is given to all COSing PCVs for two months and is a transitional insurance intended to help Volunteers return to the United States. It is not ACA-compliant. You have the option to extend coverage. If you have questions about SHIFTT, or want to extend your coverage, call IMG directly: 855.731.9442.

ii. PC-127C/209B are Authorizations for Evaluations for service related injuries or illnesses. These are typically given to you by your PCMO. If you have COS’d and need an evaluation for a service related injury or illness, contact the Post Service Unit at: psu@peacecorps.gov, or call: 202.692.1540.

1. The expiration date is located on the authorization. Legally, Peace Corps cannot extend the expiration date.

How do I locate providers within the First Health Network? To find a Doctor in your area that works within the FirstHealth Network, please click here

a. Select “First Health network” and press “Start Now” b. Select your provider type – most conditions fall under “Physician” c. Enter ZIP code d. If you need to select a specialist, click “+Show More Options”. You will have the option

to narrow the search by Specialty or Condition. Select “Specialty type”, and select the specialist if necessary. If you intend to use the Readjustment Counseling sessions, make sure to use a psychologist or a psychiatrist.

e. Press “Search now” f. Call up providers, confirm they are in the First Health Network and see if they are willing

to accept an Authorization for Evaluation. If providers have questions about payment or

coverage, direct them to call IMG at: 855.731.9442. Your Volunteer ID number is your insurance member ID, this can be located on your PC-127C/PC-209B.

What should I do during my appointment? a. Make sure to bring your PC-127C/PC-209B Authorization to the appointment. Have the

provider’s office make a copy of the authorization. The providers need to submit both the itemized bill and the PC-127C/PC-209B Authorization to IMG directly.

b. Make sure the attending physician reads the authorization and discuss the service-related condition you are going to the appointment for.

Referrals and Further Evaluations a. If you are referred to a specialist or an additional evaluation is ordered, please submit the

referral or order to the Post Service Unit via email: psu@peacecorps.gov or fax it to: 202.692.1541.

Treatment a. If treatment is indicated, it is not authorized at this point. To authorize treatment, we will

need an accepted FECA Claim. If a FECA Claim is accepted by Department of Labor, it will cover the cost of treatment for the Peace Corps related injury or illness. For additional information about FECA Claims, please contact FECA@peacecorps.gov.

b. If unauthorized treatment is received prior to the acceptance FECA Claim, the burden of payment will fall on the Volunteer.

Submitting Medical Documents a. To complete your PC Medical record, please send all Office Visit Notes to Peace Corps’ Post

Service Unit via email: psu@peacecorps.gov or via fax: 202.692.1541.

Out of Network Options a. Out of Network Options: You can go out of the IMG/First Health Network as it is a PPO

Insurance plan. Call up a local provider, ask if they accept IMG’s fee schedule or the customary allowance. If the provider wants to know what the customary allowance is, you can direct them to contact IMG, they can be reached at (855) 731.9442.

Dental Evaluations a. Typically, you will have to go out of network for a dental evaluation. Make sure to bring your

PC-127C Authorization for Dental Evaluation. If you are home, we recommend contacting your family dentist, or seeing the dentist you saw prior to Peace Corps service.

b. Before Peace Corps can approve treatment for dental issues, we need a few things. After your initial visit, you will need to ask the providers office for:

• X-rays (preferably in email, as the fax’s images aren’t as clear) • Office Visit Notes • Treatment Plan

• Itemized Bill Once you have collected all of these documents, please send them to psu@peacecorps.gov (or fax: 202.692.1541 ATTN: Dental). Once we have the documents, we will have our dental specialist review them to determine the best course of action.

Can Peace Corps provide eyeglasses? No. It is against Peace Corps policy to provide eyeglasses to RPCVs. Various price point options can be found on the internet.

Can Peace Corps issue a PC-127C for IUDs, or evaluation of IUD Placement? No. PSU cannot issue a PC-127C for IUDs, including those inserted during service. You would need to cover this issue using your SHIFTT insurance, which we highly discourage, or after you obtain good medical benefits here in the US. The RPCV may also want to search for free clinics in their area.

When will I receive my readjustment allowance? Readjustment Allowance is done on a case-by-case basis and is handled by the country the PCV/RPCV served in. If you have general questions about readjustment allowance, please contact your country staff as they will give the most accurate answers.

If there are issues with banking, contact financialinfo@peacecorps.gov, and they can be of assistance.

TG 330 ATTACHMENT A

May 2017 1

POST-SERVICE HEALTH INFORMATION

FOR RETURNING VOLUNTEERS

Please carry this important handout in your personal belongings.

Post-Service Health Benefits

Returning Volunteers are covered by a three-tiered health benefits program. Two mechanisms – Peace

Corps authorizations (PC-127C) and Federal Employee Compensation Act (FECA) benefits – cover

service-related medical expenses. The third – RPCV Short-term Health Insurance For Transition &

Travel – completes the benefit package by giving you access to an affordable medical policy you can

use to meet non-service-related health care expenses while transitioning into private health insurance.

This table is a synopsis of your health benefits program. Detailed information about each mechanism

appears in sections below:

POST-SERVICE HEALTH BENEFITS

Benefits

Mechanism

Covers Time Limit How Accessed

PC-127C

Authorizations

Evaluation of medical and

dental health conditions related

to overseas service.

Must be issued and used

within 6 months of COS.

Preferably used with a Peace

Corps Health Benefits

Identification Card.

May be issued by PCMOs or

the Office of Health Services

(OHS) staff.

FECA

Benefits

Treatment for medical and

dental conditions related to

overseas service.

Claims must be filed within 3

years of COS or within 3 years

of recognition that a health

condition is service-related.

Claims are filed through OHS

Post-Service Unit.

RPCV

Short-term

Health

Insurance

For

Transition &

Travel

(SHIFTT)

Non-service related medical

problems.

Specifically:

Pre-existing conditions

not covered by FECA

Conditions that arose

while in the U.S. on

vacation, home leave,

emergency leave or

medevac

New health problems

after COS

Peace Corps pays one month’s

premium for all Volunteers.

Volunteers may purchase an

additional 2 (two) months of

coverage for themselves and

their qualified dependents

while transitioning to private

insurance.

Contact International

Medical Group (IMG)

Customer Service for:

Emergency medical

assistance

Referrals to Network

hospitals,

physicians, or other

health services

Insurance coverage

extensions

PC 127C Authorizations

A 127C is used to authorize payment of expenses for medical and dental evaluations of health conditions

that are related to your overseas service.

TG 330 ATTACHMENT A

3

May 2017

Only evaluations are covered, and only the specific evaluation authorized will be reimbursed. A 127C

cannot be used for medical treatment.

You must use a 127C within 6 months of your close of service (COS) date. It will not be honored after

that time has elapsed.

A 127C may be issued by a PCMO, a Regional Medical Officer (RMO) or Office of Health Services

(OHS) staff. The 127C form is generated from the electronic medical record system. It can be provided

to you either in electronic or hard copy format. You should print out and sign a copy to provide to your

healthcare provider with whom you consult.For questions regarding 127C authorizations, FECA

benefits or other service-related health issues, you should contact the OHS Post-Service Unit at

psu@peacecorps.gov. In the U.S., you may call (toll free) 855-855-1961, extension 1540. Outside the

U.S., you may call 202-692-1540.

A 127C authorization should be used in conjunction with your Peace Corps Health Benefits

identification card. For questions regarding the use of the Health Benefits ID card, you should contact

OHS Post-Service Unit at psu@peacecorps.gov or 855-855-1961, extension 1540. For information on

network providers in a particular geographic location, you should contact International Medical Group

at 1-855-731-9442 or visit their website at http://peacecorps.imglobal.com.

To extend RPCV Short-term Health Insurance for Transition & Travel coverage, you should contact

the plan administrator, International Medical Group. Their phone numbers are 1-855-731-9442 in the or

317-927-6825 outside the U.S. You may use IMG's website to see a copy of the RPCV Short- term

Health Insurance For Transition & Travel policy or to check personal coverage (go to

http://peacecorps.imglobal.com and click the “RPCV Short-Term Insurance” button).

For information or assistance with a medical emergency or a non-service-related health problem,

returned Volunteers enrolled in RPCV Short-term Health Insurance For Transition & Travel should

contact IMG directly. In the U.S., they should call 855-731-9442. Outside the U.S., they may call

317-927-6825.

Federal Employee’s Compensation Act Benefits (FECA)

FECA pays for medical treatment for health conditions related to your overseas service.

FECA benefits are administered by the U.S. Department of Labor (DOL) Office of Workers’

Compensation Programs (OWCP). The Post-Service Unit in OHS can assist you in filing claims for

benefits.

FECA benefits are not guaranteed. OWCP must determine that your health condition is service-related

before a claim for benefits is accepted.

OWCP claims processing usually takes from six to twelve weeks. This process can be expedited if you

contact the Post-Service Unit as soon as you believe you have a service-related condition requiring

treatment and if you respond quickly to requests for information from the Post-Service Unit or OWCP.

Claims must be filed within 3 years of COS or within 3 years of recognition of a service-related health

condition.

Health problems resulting from injuries or illnesses that develop in the U.S. while you are on vacation,

home leave, emergency leave or on medevac but not directly engaged in Peace Corps activity are not

eligible for FECA benefits (see RPCV Short-term Health Insurance For Transition & Travel below).

The Post-Service Unit in OHS can provide information on FECA claims processing. You can get

additional information at www.peacecorps.gov/resources/returned/healthben/feca/

TG 330 ATTACHMENT A

4

May 2017

Health Insurance For Transition & Travel coverage will cease. Volunteers should contact RPCV

Short-term Health Insurance For Transition & Travel Customer Service for full information on

After Corps coverage issues.

RPCV Short-term Health Insurance For Transition & Travel Insurance

RPCV Short-term Health Insurance For Transition & Travel is a health insurance policy

designed specifically for returned Volunteers

RPCV Short-term Health Insurance For Transition & Travel can be activated only at COS. It

provides coverage for non-service related healthcare needs, specifically:

1. Pre-existing conditions: Health conditions that existed prior to Peace Corps service that

were not affected by Peace Corps service.

2. Travel to the U.S. on personal business: After COS, RPCV Short-term Health Insurance

For Transition & Travel will cover health problems that developed while a Volunteer was on

personal business in the U.S., e.g. vacation, home leave, emergency leave but not directly

engaged in Peace Corps activity.

3. Healthcare after COS: Returned Volunteers need health insurance for new health problems

that arise after COS.

Peace Corps pays the first month’s premium for you when you leave service.

At COS, you may elect to continue RPCV Short-term Health Insurance For Transition & Travel

for two months of additional coverage. You may also enroll and extend benefits for qualified

dependents.

Payment for extended coverage for yourself and for qualified dependents may be made by check,

credit card or through a deduction in your readjustment allowance.

RPCV Short-term Health Insurance For Transition & Travel requires re-certification for medical

transportation other than local ground services and strongly advises Volunteer to confirm benefits

prior to use of (1) overseas healthcare and (2) U.S. healthcare expected to be more expensive than

the cost of a physician office visit.

You may not use RPCV Short-term Health Insurance For Transition & Travel insurance to cover

medical expenses provided for under 127C authorizations or FECA. If you do not know which

benefit plan to use, contact the Post-Service Unit in OHS.

Peace Corps pays only for the first month’s premium on your RPCV Short-term Health

Insurance For Transition & Travel insurance. Before you leave service, you will be given an

insurance card and an application that allows you to purchase up to two months additional

coverage for yourself and for your qualified dependents. Peace Corps strongly encourages you

to sign-up for extended RPCV Short-term Health Insurance For Transition & Travel coverage

before you leave country. If this policy lapses, for even one month, you will not be eligible

to rejoin the plan. You may alternatively transition immediately into private insurance.

TG 330 ATTACHMENT A

5

May 2017

Health Information before You Leave Country

Before you leave country, you may ask your Peace Corps Medical Officer (PCMO) to let you review your

health record. You should confirm that all significant health problems you had in country are

documented. You may ask for a copy of the PCMEDICS Continuity of Care Record (CCR) which

provides an overview of the health care provided while in service. If you have a problem that cannot be

resolved before you depart, the PCMO will give you a 127C authorization. This form authorizes and

evaluation of your condition by a medical professional.

Important Contact Information

Health Information after You Leave Country

For questions regarding 127C authorizations, FECA benefits or other service-related health issues,

contact the Post-Service Unit in OHS at psu@peacecorps.gov. In the U.S. call 1-855-855-1961,

extension 1540 (toll free). Outside the U.S., call 202-692-1540.

For questions regarding the use of the International Medical Group Health Benefits identification

card. Contact IMG, Peace Corps Health Benefits Program at 855-731-9442. For information on

Network providers in a particular geographic location, see http://peacecorps.imglobal.com.

Numbers are also listed on the Health Benefits identification card and the “Instructions for Use”

information sheet.

To extend RPCV Short-term Health Insurance For Transition & Travel insurance coverage,

contact the plan administrator, International Medical Group. Their phone numbers are

855-731-9442 in the U.S. or 317-927-6825 outside the U.S. You may use International Medical

Group website to see a copy of the RPCV Short-term Health Insurance For Transition & Travel

policy or to check personal coverage. (Go to http://peacecorps.imglobal.com and click the “RPCV

Short-Term Insurance” button.)

For information or assistance with a medical emergency or a non-service-related health problem,

returned Volunteers enrolled in RPCV Short-term Health Insurance For Transition & Travel

should contact International Medical Group at 855-731-9442 or 317-927-6825.

Peace Corps CONSENT/AUTHORIZATION FORM

REMINDER: THIS IS COMPLETELY VOLUNTARY

I, ,hereby authorize the Peace Corps Office of Health Services, Post-Service Unit to

communicate with me by electronic mail at the e-maiI address referenced below and/or by telephone text at the telephone

number listed below. I understand that protected health information, which may include personally identifiable and

medically sensitive information about me, may be included in such communications.

This disclosure is at my request. I understand that there is some risk of inadvertent disclosure to unauthorized persons

during transmission. I understand that the information disclosed pursuant to this consent is subject to re-disclosure by the

recipient(s), which may result in the loss of Privacy Act or Health Insurance Portability and Accountability Act (HIPAA)

protections. I understand that I may also revoke this authorization in writing at any time.

It is my responsibility to notify Peace Corps of any change in my email address or telephone number.

Current email address to be used for receipt of medically sensitive information:

Current telephone number to be used for texting medically sensitive information:

Signature (Full Name) Date of Birth Date

1275 First Street NE Washington, DC 20526

PC-1790 (COS/EXT) Peace Corps Close-of-Service or Extension-of-Service Medical Evaluation

Please use this form when conducting a close-of-service or extension-of-service medical examination. All items must be completed as instructed.

This information will be used to assist in providing appropriate medical follow-up after Peace Corps service and to facilitate Worker’s Compensation claims.

Incomplete information may interfere with post-service health care.

Name: (Last, First, Middle Initial Sex M F Social Security Number Date of Birth (Mo/Day/Yr) Country of Service

Date of Exam (Mo/Day/Yr)

Telephone No.

( ) Home/permanent address

Section One

To be completed by volunteer

I. Health History

A. Instructions to Volunteer Please answer each question by indicating if you have experienced any of the following during Peace Corps service by checking No, Yes (Resolved), or Yes (Current). Comment in the space provided.

Symptoms or problems during Peace Corps service No Yes (Resolved)

Yes (Current)

Volunteer Comments

Weight gain or loss of more than 10 pounds □ □ □

Frequent or severe headaches □ □ □

Fainting spells or blackouts □ □ □

Vision problems, eye injuries or disorders □ □ □

Hearing problems □ □ □

Persistent cough □ □ □

Chest pain or chest pressure □ □ □

Shortness of breath or wheezing □ □ □

Repeated episodes of indigestion, heartburn, or stomach pain □ □ □

Frequent diarrhea □ □ □

Frequent constipation □ □ □

Frequent or painful urination □ □ □

Blood in your urine □ □ □

Repeated episodes of back or neck pain □ □ □

Muscle, bone, or joint injuries □ □ □

Painful or swollen joints □ □ □

Breast lump or mass, or nipple discharge □ □ □

Skin problems (e.g. eczema, dermatitis) □ □ □

Change in color or size of a mole or other growth □ □ □

A sore which does not heal □ □ □

Frequent sadness or feelings of depression □ □ □

Frequent or severe nervousness or anxiousness □ □ □

Frequent sleeplessness or insomnia □ □ □

Use of cigarettes or other tobacco products □ □ □

(Females) Gynecologic symptoms or disorders □ □ □

Revised April 2007 Page 2 of 4

SSN

B. List all other current problems not described in Section A C. List all current medications, including over-the-counter medications/preparations Name Dose Frequency D. List all medication or vaccine allergies Name of medicine/vaccine Type of reaction Section Two II. Review of History and Medical Evaluation

To be completed by PCMO or examining physician

A. Review of Medical History Review the medical history provided in Section I. Use the space below to provide additional comments as necessary. Ensure that all problems that occurred during service are well documented in the health record or on this form.

B. Measurements and Other Findings Height Weight Blood

Pressure Pulse Hearing Gross Vision

Uncorrected Corrected Right 20/___ Right 20/___ Left 20/____ Left 20/____

feet/inches lbs. mmHg (resting)

bpm (resting) (whisper test of other

gross test)

Revised April 2007 Page 3 of 4

SSN

C. Clinical Examination To be completed by PCMO or examining physician

Normal Abnormal Check each item in appropriate column. All systems must be examined.

Notes: Describe each abnormality in detail Enter item number before each comment. Use additional sheets if necessary.

□ □ 1. Head and neck

□ □ 2. Nose, sinuses

□ □ 3. Mouth and throat

□ □ 4. Thyroid

□ □ 5. Ears

□ □ 6. Eyes (include fundoscopic exam)

□ □ 7. Lungs and chest

□ □ 8. Breasts

□ □ 9. Cardiac (rhythm and abnormal heart sounds)

□ □ 10. Peripheral pulses

□ □ 11. Abdomen

□ □ 12. Prostate exam (men, over 50 only)

□ □ 13. Anus and rectum

□ □ 14. Genitalia (include hernia)

□ □ 15. Pelvic exam (females only)

□ □ 16. Spine

□ □ 17. Musculoskeletal

□ □ 18. Neurologic

□ □ 19. Skin, lymphatics

□ □ 20. Identifying marks, scars, tattoos

□ □ 21. Psychiatric (specify any significant cognitive or behavioral observations)

D. Laboratory Findings (PCMO: For any test not performed/ordered document rationale in Section F on page 4) Urinalysis Hematocrit OR Hemoglobi

n G6PD Status (check one)

Tuberculin Test (5 IU PPD)

Albumin If terminal prophylaxis with primaquine is indicated.

Date read mm of induration

Sugar □ Normal □ Deficient Blood If deficient, do not dispense

primaquine. Do not report “negative.” Size of induration must be noted. Include Ø

Other % Grams Stool for ova and parasites (3x)

Schistosomiasis serology

PAP smear cytology results

Chlamydia/GC HIV serology

(check one) (check one) (check one) (check one) (check one) If intestinal parasites are endemic

Indicated if PCV is leaving or has traveled to an endemic area

□ Specimens to _____________________

□ Specimens to CDC □ Specimens to _____________________

□ Specimens to _____________________

□ Specimens to _____________________

On Date:______________ On Date:______________ On Date:______________ On Date:______________ On Date:______________

□ 127C issued □ 127C issued □ 127C issued □ 127C issued □ 127C issued

□ 209B issued □ 209B issued □ 209B issued □ 209B issued □ 209B issued

□ Results attached □ Results attached □ Results attached □ Results attached □ Results attached

Revised April 2007 Page 4 of 4

SSN

E. Required Tests for Volunteers 40 Years and Older (not required of other Volunteers unless clinically indicated)

Stool Test for Occult Blood x 3(for PCVs > 50 yo) Mammogram (for females over 40 years old) 1. Date ________________________ Pos □ Neg □

Mammogram to be performed in the U.S. after COS

2. Date ________________________ Pos □ Neg □ □ 127C issued 3. Date ________________________ Pos □ Neg □ □ 209B issued

F. Summary of the Medical Examination and Additional Comments

The information requested is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et Seq., for the purposes of documenting the basis for requested payments. Disclosure of this information is voluntary, but failure to do so will make it impossible for the Peace Corps to pay for these services. This information may be used for the routine uses described in the Privacy Act, 5 USC 552a, and in the Federal Register at 65 Fed. Reg. 53,722 (September 5, 2000) and 50 Fed. Reg/ 1950, 1962 (January 14, 1985) regarding Peace Corps system of records PC-17 (volunteer records). It may also be subject to the Health Insurance Portability and Accountability Act (HIPAA).

*Important*

Incomplete forms may be returned and may delay processing!

COS is complete only when: PCMO/Physician Signature Date

1 Volunteer has completed Section I (Health History).

(Must be signed or co-signed by a licensed M.D. or D.O. if exam performed by PA or NP)

2 PCMO or examining physician has completed

Section II

3 Appropriate laboratory studies have been performed or ordered.

PCMO/Physician license number State

4 The Summary of Medical Examination has been

completed. 5 Examining physician has signed the report or has co-

signed the clinical examination performed by NP or PA. Physician address and phone number (unless performed by PCMO)

HIPAA and Privacy Act Notice: The information requested is collected under authority of the Peace Corps Act for the purpose of documenting the basis for requested payments. Disclosure of this information is voluntary. However, failure to disclose the information will make it impossible for Peace Corps to pay for these services. This information will be maintained under the provisions of HIPAA and under the provision of the Privacy Act for routine uses described in the Federal Register of August 27, 1984 (relating to Peace Corps Volunteer medical records).

For Peace Corps use only

To be completed by PCMO—Refer to Technical Guidelines

□ Medically cleared by PCMO for extension of service or transfer. No significant undiagnosed, unresolved, or potentially recurrent health conditions.

□ Medically cleared or provisionally medically cleared by OMS for extension of service or transfer. Consultation by PCMO with OMS is required for undiagnosed, unresolved, or potentially recurrent health conditions.

□ Not medically cleared for extension of service or transfer due to significant unresolved or potentially recurrent health conditions. Consultation by PCMO with OMS is required.

I. General Dental Evaluation

A. Chart existing restorations, missing teethand endodontically treated teeth: ➤

❏ Check here if no existingrestorations, missing teethor endodontically treated teeth

OR

Comment on findings:

Check one:

❏ Pre-service dental exam

❏ Post-service dental exam

❏ Other (please specify)

B. Chart diseases, abnormalities andall recommended treatment: ➤

❏ Check here if no disease, abnormalityor recommended treatment

OR

Comment on findings:

PEACE CORPS USE ONLY

PC-1790 (Dental)

Peace CorpsReport ofDental Evaluation

Name: (Last, First, Middle Initial) Sex M ❒ F ❒

Social Security number Date of birth (MO / DAY / YR)

Country of service Date of exam (MO / DAY / YR)

Home/permanent address

Telephone No. ( )

/ /

/ /

Page 1 of 4

Page 2 of 4

Applicant SSN:

Peace Corps · Report of Dental Examination

II. Periodontal EvaluationA. Chart periodontal probings, gingival recession, and mobility

Calculus Deposits: ❏ Light ❏ Moderate ❏ Heavy

B. Identify by number all teeth with:

Areas of bleeding upon probing ❏ None ❏ Affected teeth: ________________________________________

Areas of suppuration ❏ None ❏ Affected teeth: ________________________________________

Furcation involvement ❏ None ❏ Affected teeth: ________________________________________

Insufficient attached gingiva ❏ None ❏ Affected teeth: ________________________________________

C. Periodontal Classification:

❏ No Disease ❏ Class I: Gingivitis

❏ Class II: Early Periodontitis

❏ Class III: Moderate Periodontitis

❏ Class IV: Advanced Periodontitis

D. Recommended periodontal therapy:

Buccal

Lingual

Buccal

Lingual

Lingual

Buccal

Lingual

Buccal

Page 3 of 4

Applicant SSN:

Peace Corps · Report of Dental Examination

III. Third Molar Evaluation

❏ No history of pericoronitis ❏ Third molar extraction not recommended

❏ History of pericoronitis ❏ Third molar extraction recommended

Please provide dates: Please specify recommended extractions:

IV. TMJ Evaluation

❏ No history of TMD

❏ History of TMD Symptoms

Please describe treatment provided, dates, and if symptoms are present at this time:

V. Bruxism

❏ No history of bruxism

❏ History of bruxism

Please describe any bruxism habit, presence of wear facets or need for occlusal guard:

VI. Prosthesis

❏ No prosthesis present

❏ Prosthesis present

Please describe the nature and extent of the prosthesis (e.g. full or partial dentures, bridge, etc.)and the need for repair or replacement:

VII. TreatmentList all treatment completed after this examination. Do not include treatment planned but not yet completed.

Treatment Date Signature

Page 4 of 4

Applicant SSN:

Peace Corps · Report of Dental Examination

* Important *Dental examination iscomplete only when:

1 The dentist has completed all sectionsof the charting form.

2 The dentist has signed and dated the form.

3 The dentist has listed all treatment completedin Section VII.

➤ Applicants only:The dentist has included one of thefollowing sets of x-rays:

1) A full mouth series, or2) A Panorex with bitewing x-rays.

· Periapical or Panorex films must beless than two years old.

· Bitewing x-rays must be less thanone year old.

· All films must be original films,not duplicates.

➤ Close-of-service only:The dentist has included bitewing x-rays.

Office of Medical Services Dental Consultant · Dental Clearance Notes and Recommendations

❒ Dental Clearance Pending Date

Reason for Pending:

❒ Dental Clearance Date

❒ Dental Clearance with Restrictions Date

Specify restrictions:

FOR PEACE CORPS USE ONLY ➤

Dentist’s signature

Date

Dentist’s License number State

Dentist’s name, address and phone number

INCOMPLETE FORMS WILL BE RETURNEDAND MAY DELAY PROCESSING!

For 127C billing issues, contact psu@peacecorps.gov.For RPCV Short-term Health Insurance For Transition & Travel (SHIFTT) billing issues, contact International Medical Group, Inc. (IMG) at 855.731.9442.

The Peace Corps is a federal agency created and governed by a congressional act, the Peace Corps Act. Under this act, the Peace Corps does not have the legal authority to pay for or provide health care for returned Volunteers. If you are seeking treatment for a servicerelated illness or injury , see the FECA section inside this brochure.

No. The 127C authorizes an evaluation of conditions that resulted from Peace Corps service. RPCV Short-term Health Insurance For Transition & Travel is temporary health insurance used for health conditions that occur after service, and both have unique ID cards.

Imaging studies (X-ray, MRI, ultrasound), lab tests, mental health evaluations, and physician consultation. If you or your provider have questions about coverage, please contact psu@peacecorps.gov.

Yes. You can file after you receive treatment, but as with all claims, acceptance is not guaranteed and you may not be reimbursed for the cost or your care. Claim decisions are made by the Department of Labor, not the Peace Corps. For more detailed information, visit dol.gov/owcp/dfec/fec-faq.htm.

The Peace Corps Post-Service Unit is part of

the Office of Health Services at Peace Corps

headquarters in Washington, D.C. We

administer the three post-service health care

benefits available to returned Peace Corps

Volunteers.

PEACE CORPS POST-SERVICE UNITPaul D. Coverdell Peace Corps Headquarters 1275 First Street NE Washington, DC 20526

psu@peacecorps.gov 855.855.1961 TOLL–FREE 202.692.1540 MAIN 202.692.1541 FAX

PEACECORPS.GOV

A GUIDE FOR HEALTH BENEFITS AFTER SERVICE

PEACE CORPS POST-SERVICE UNITPaul D. Coverdell Peace Corps Headquarters 1275 First Street NE Washington, DC 20526

psu@peacecorps.gov 855.855.1961 TOLL–FREE 202.692.1540 MAIN 202.692.1541 FAX

PEACECORPS.GOV

Why can’t the Peace Corps continue providing my

treatment when I return to the U.S.?

Do I need to use a 127C to use SHIFTT?

What qualifies as diagnostic testing/

evaluation under the 127C?

I want to file a FECA claim but I have an urgent

medical condition. Can I receive treatment, then file for reimbursement?

FAQsI used a 127C Form/SHIFTT

and my provider is billing me. Who can I contact?

8/17

PEACECORPS.GOV

How can Post-Service Unit (PSU) help you?

• Guide you through the post-service health care process

• Assist you in using your 127Cs toreceive consultation/diagnostic testing of medical conditions from service, then help you file your Federal Employees’ Compensation Act (FECA) claim with the Department of Labor (DOL)

• Provide you with additional 127Cs ifmore diagnostic testing is needed

• Act as a liaison between you andDOL once your FECA claim has been filed

Short-term Health Insurance For Transition & Travel (SHIFTT)

What is SHIFTT?SHIFTT is transitional health insurance

for RPCVs that covers health conditions developed after service.

Who can enroll?All Peace Corps and Peace Corps Response Volunteers are automatically enrolled for the first month after service. Spouses and dependents of Volunteers can enroll for additional cost.

How much does it cost?All returned Volunteers' first month is paid for by the Peace Corps. You may enroll for a maximum of two additional months at your expense, which can be deducted from your readjustment allowance. To extend coverage, you must enroll within 31 days after your close of service (COS) date.

What does SHIFTT cover?SHIFTT covers you internationally and in the U.S. For information regarding coverage, cost, and to access the First Health Provider Network, visit peacecorps.imglobal.com.

PC-127C Form for Medical and Dental Authorization

What is the 127C?Regardless of your health insurance status, this form authorizes you to receive physician consultation/diagnostic testing in the U.S. at the Peace Corps’ expense for health conditions not resolved during service.

How do I get a 127C?You will receive a 127C from your Peace Corps Medical Officer at COS or from the PSU after you return to the U.S.

How do I use the 127C?Follow these three steps:

1. Choose a health care providerto visit for the condition listed on your 127C.

2. Present the 127C and your Health Benefits Program ID card (pictured left) to the medical care provider as payment for your visit. Explain that you have an “authorization for evaluation” and direct them to billing instructions on the 127C.

3. If further evaluation/diagnostic testing is needed, additional 127Cs may be provided by PSU.

IMPORTANT: The 127C does not authorize treatment. You may choose to file a FECA claim (benefit 3, right) for treatment.

IMPORTANT: 127Cs can only be used within six months of your close of service/early termination (ET).

For more detailed information, visit:dol.gov/owcp/dfec/fec-faq.htm.

I am traveling after service and haven’t elected U.S. health insurance yet. What if I get hurt?

How do I receive further medical treatment after service or treatment for conditions diagnosed using a 127C?

There are three post-service health care benefits available to returned Peace Corps Volunteers (RPCVs):

IMPORTANT: SHIFTT is designed to be transitional health insurance after service. It is your responsibility to elect a health insurance plan, within 60 days of your return to the U.S., to comply with the Affordable Care Act. For more information,visit www.healthcare.gov.

Calculating Your Plan Cost (Please complete entire section.)

Please use the following chart to extend your coverage and determine your premium based on your plan of choice. Extension coverage begins after the first month.

Months RPCV Premium SubtotalVolunteer: X $ = $Spouse: X $ = $Dep #1: X $ = $Dep #2: X $ = $

Total Extension Premium = $

Payment (Select One)

Peace Corps Readjustment Allowanceq Submitted to Peace Corps Administrative Office prior to COS Date.Check/ Money Orderq Check enclosed, payable to IMG q Money Order enclosed, payable to IMGCredit Cardq Pay in Advance q Automatic Monthly Deduction

To Submit ApplicationIMGAttn: Peace Corps CareMailing Address: P.O. Box 88506, Indianapolis, IN 46208-0500Fax: 855.731.9443

q MasterCard q Visa q Discover q American Express Card Number: CVV: Expiration Date: Daytime Phone: ( ) Name on Card: Billing Address: Signature

(Required)

IMPORTANT! Your permanent medical ID card is below. This is for your RPCV Short-Term Health Insurancefor Transition and Travel coverage. Carry it with you at all times.

6

*Your ID # will be the numeric value of your Peace Corps ID

Administered By: IMGpeacecorps.imglobal.com

Member:ID#: PEAC4 Date Issued:

Returned Peace Corps Volunteers (RPCV)

For pre-notification of emergencyand non-emergency medicaltreatment, an explanation ofmedical benefits, claim status,to find an in network provider,to extend your coverage,or verify payment, contact:

AssistancePCcare@imglobal.com855.731.9442 or 317.927.6825peacecorps.imglobal.com

Co-payments$25/$35 office visits,$50 Urgent Care, $100 ER visit

Contact 855.731.9442 or317.927.6825 or you may access alist of in network pharmacies atpeacecorps.imglobal.com

Use BIN#: 610020 andGroup#: RX99992794Only the primary policy holder iscovered for pre-existing conditions.

To submit claims:IMGAttn: Peace Corps CareP.O. Box 88506, Indianapolis, IN 46208-0500Fax: 855.731.9443Email: PCcare@imglobal.com

Cut on dotted line, fold in half, and place in your wallet.PC-127C I.D. Card

SHIFTT I.D. Card

I have a medical condition from my Peace Corps service and need diagnosis and/or a treatment plan in the U.S. What are my next steps when I return to the U.S.?

Federal Employees' Compensation Act (FECA)

What is FECA?FECA is the law that provides compensation benefits for individuals who are injured or develop conditions while on duty with the federal government. This includes Peace Corps Volunteers. FECA provides a variety of benefits for injury, illness or disability where a volunteer has a service-connected medical condition.

When Should I file a FECA Claim?A FECA Claim must be filed within three years of the date of injury or when aware that the condition is service-related. If it is determined by your health care provider (that you saw independently or by using a 127C) that you need treatment, it is your right to file a FECA claim to seek compensation benefits in such circumstances.

How do I file a claim?Contact PSU to guide you through the process. You will need to complete a claim form and request your doctor’s visit notes to submit with your claim.

What happens after I file a claim?Your PSU nurse will be in contact with your DOL claims examiner. Claim decisions are made by DOL not the Peace Corps.

PEACE CORPS

Office of Health Services

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION

Instructions: To be completed by the (Returned) Volunteer.

Send completed forms to: medrecords@peacecorps.gov or Fax: 202.692.1577 ATTN: Med Records

COMPLETE ALL SECTIONS, DATE AND SIGN

1. Patient Name: ____________________________________ Volunteer ID (if known):_______________________________

Date of Birth __________/________/________ (mm/dd/yyyy)

Address: ____________________________________ City: _______________ State: _____________ Zip Code: _________

Email Address: _________________________________________ Phone: ______________________________

4. I authorize the following PHI to be released from my medical records:

All Records Immunization Records Dental Records

Pre-Service Health Records In-Service Health Records Post Service Health Records

Consultant Reports Sexual Assault Records

2. I request that my protected health information (PHI) from the Peace Corps be disclosed to:

Recipient Name: _____________________________________________________________________________

Address: __________________________________ City: __________________________ State: ___________ Zip Code: _________

E-mail Address: ____________________________________ Phone: ____________________________

Fax (healthcare provider only): __________________________________________________

3. The purpose or need for this disclosure is:

Continuing Care Personal Use School Other (Specify) ___________________

I understand that the information in my medical record may include information related to sexually transmitted diseases including HIV/AIDS. It mayalso include information about behavioral and mental health services and/ or alcohol and drug abuse treatment. I agree to have the following information released:

Sexually Transmitted Infections: Yes No Mental Health Information: Yes No

Substance Abuse/Treatment (Drug/Alcohol) Yes No HIV/AIDS Information Yes No

Term: I understand that this Authorization will remain in effect:

From the date of this Authorization until ________/__________/_______________ (mm/dd/yyyy)

Redisclosure: I understand that Peace Corps cannot guarantee that the recipient will not redisclose my health information to a third par ty. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health infor-mation. Refusal to sign/right to revoke: I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services from the Peace Corps healthcare facilities. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation to the Office of Inspector General at the address listed below. The revocation will be effective immediately upon my healthcare provider’s receipt of my written notice, except that the revo-cation will not have any effect on any action taken by my healthcare provider in reliance on this authorization before it received my written notice of revocation.

Questions: I may contact the Office of Inspector General for answers to my questions about the privacy of my health information at

OIG@peacecorps.gov , by phone 800-233-5874 or mail to:

Office of Inspector General P.O. Box 57129 Washington, DC 20037-7129.

Signature of Patient or Personal Representative (State Relationship to Patient) Date

Signature of Witness Date

Thank you for your service!

Attention: Peace Corps CareMailing Address: P.O. Box 88506, Indianapolis, IN 46208-0500Street Address: 2960 N. Meridian Street, Indianapolis, IN 46208

Phone: 855.731.9442 or Collect: 317.927.6825 | Fax: 855.731.9443 | Email: PCcare@imglobal.com

peacecorps.imglobal.com

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