Program participation and claims submission.

CFR · 2024-01-01 · US · Title 14

(a) (b) (2) [Reserved] (c) (2) (3) (4) (d) (e) (ii) NASA will provide specific forms appropriate for making a claim for medical monitoring, diagnosis, and treatment. Claim forms may be obtained from the JSC Flight Medicine Clinic. Contact information can be found at: (2) (i) Statement of eligibility describing the employment and spaceflight history that justifies medical monitoring, diagnosis, and treatment under this program; (ii) History and diagnosis of medical or psychological condition; (iii) Medical documentation in support of the claim. Healthcare providers must be licensed and permitted to practice under state law and not be on the Centers for Medicare & Medicaid Services (CMS) List of Excluded Individuals and Entities, found at: (iv) Documentation of the decisions and/or payments made by the primary payer ( (v) Justification for determination that the psychological or medical condition is associated with spaceflight; (vi) Expenses for which they are seeking reimbursement, to include documentation of all out-of-pocket costs; and (vii) The signature of the eligible individual or their authorized representative. (3)

official document · source cfr-2024 · id 14:§ 1241.30