U.S. Department of Labor

Office of Workers' Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

Transplant Authorization Request

Note: Please read the instructions carefully before completing this authorization request. Complete all 

applicable fields. All requests with supporting documentation must either be faxed to 1-800-882-6147 or 

be submitted through the Web Bill Processing Portal (https://owcpmed.dol.gov). Please include the 

Claimant Case ID on all pages. Incomplete requests cannot be processed and will be returned.

OMB Control No: 1240-0060 

Expiration Date: 05/31/2024

PART A: Requestor Information

A1. Date Requested:

A2. Requested By: A3. Phone Number

PART B: Claimant Information

B1. Claimant’s Case ID:

B3. First Name:

B2. Date of Birth:

B4. Last Name:

PART C: Provider Information

C1. OWCP Provider ID: C2. Tax ID (SSN/FEIN):

C3. Name: C4. Fax Number:

PART D: Treating Physician Information

E1. Diagnosis Codes: A. B. C. D.

E2.

From Date To Date Diagnosis 

Pointer 

A B C D

Code 

Type

Procedure 

Code

E3. Remarks:

Page 1

Form EE-30 

August 2020

B5. Authorized Representative: B6. Phone Number

PART E: Service Line Information

D1. Treating Physician:

D2. Treating Physician Address:
Page 2

PART G: Supporting Documents

All supporting documents must be attached to the request. Failure to include supporting documentation may result in a delay in processing or 

denial. Please include claimant’s case ID on each page. Required documentation:

Instructions

Part A: Requestor Information

A1. Type or print date on which this template is being completed Required

A2. Type or print name of the person requesting an authorization Required

A3. Type or print phone number of the person requesting an authorization

Part B: Claimant Information

B1. Type or print claimant’s case ID Required

B2. Type or print claimant’s date of birth (mm/dd/yyyy) Required

B3. Type or print claimant’s first name Required

B4. Type or print claimant’s last name Required

B5. Type or print authorized representative’s name

B6. Type or print authorized representative’s phone number

Form EE-30 

August 2020

PART F: Transplant Information

F1. Transplant Facility: F2. Transplant Type:

F5. Organ Transplant Coordinator Name: F6. Phone Number:

F3. Transplant Facility Address:

F4: Transplant Facility Phone:

Letter of medical necessity from the treating physician describing the need for the transplant being requested.

Initial and recent clinical evaluation (i.e., diagnostic studies and laboratory tests)

A copy of the treatment protocol

Part C: Provider Information

C1. Type or print service rendering provider’s OWCP ID Required

C2. Type or print provider’s Tax ID (SSN or FEIN) Required

C3. Type or print provider’s name Required

C4. Type or print fax number. If entered, this fax number will be used for communication related to 

this authorization request. Leave it blank if fax number was provided during provider enrollment.

Part D: Treating Physician Information

D1. Type or print referring physician’s name Required

D2. Type or print referring physician’s address Required

Part E: Service Line Information

E1. Type or print ICD-09 or ICD-10 diagnosis codes for which services are being rendered, up to 4 

codes are allowed. 

ICD-9 code is applicable if date of service is prior to 09/30/2015. Use ICD-10 code if date of 

service is after 10/01/2015.

E2. Service lines

Type or print beginning date of the service Required

Type or print end date of the service Required

Select diagnosis code pointer from the diagnosis codes listed in Part D: A, B, C, D Select all 

applicable options.

Required
Page 3

Form EE-30 

August 2020

PUBLIC BURDEN STATEMENT 

 

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a 

collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 

1240-0060. There are no penalties for failure to supply information; however, failure to furnish information regarding the medical service(s) 

requested will prevent payment of the bill. We estimate that it will take an average of ten minutes to complete this collection of information, 

including time for reviewing instructions, abstracting information from the patient’s records and entering the data onto the form. This time is 

based on familiarity with standardized coding structures. Send comments regarding this burden estimate or any other aspect of this collection 

of information, including suggestions for reducing this burden, to the Department of Labor, Office of Workers’ Compensation Programs, Division 

of Energy Employees Occupational Illness Compensation, Room C3321, 200 Constitution Avenue NW, Washington, DC 20210. DO NOT 

SEND THE COMPLETED FORM TO THIS OFFICE.

PRIVACY ACT STATEMENT 

 

The Privacy Act of 1974, as amended (5 U.S.C. 552a) authorizes OWCP to ask you for information needed in the administration of the 

EEOICPA program. Authority to collect information is in 42 USC 7384d, 20 CFR 30.1 et seq. and E.O. 13179. The information we obtain is 

used to decide if the services and supplies being billed for are covered by the program and to insure that proper payment is made. There are 

no penalties for failure to supply information; however, failure to furnish information regarding the medical service(s) at issue will prevent 

payment of the bill. Failure to supply the claim number or CPT codes will delay payment or may result in rejection of the authorization request 

because of incomplete information. 

 

We are authorized to request a taxpayer identification number (TIN) or Social Security Number (SSN) under the Debt Collection Improvement 

Act of 1996, 31 U.S.C. 7701(c)(1), which mandates us to require persons who are doing business with a Federal agency to furnish a TIN or 

SSN. The SSN or TIN, and other information maintained by us may be used for identification, to support debt collection efforts carried on by the 

Federal government, and for other purposes required or authorized by law. Additional disclosures are made through routine uses for 

information contained in systems of records. See Department of Labor system DOL/OWCP-11 published in the Federal Register, Vol. 81, page 

25868, April 29, 2016, or as updated and republished. 

 

You should be aware that P.L. 100-503, the “Computer Matching and Privacy Protection Act of 1988,” permits the government to verify 

information by way of computer matches..

Part F: Transplant Information

F1. Type or print transplant facility Required

F2. Type or print transplant type Required

F3. Type or print transplant facility address Required

F4. Type or print transplant facility phone Required

F5. Type or print name of person coordinating the organ transplant Required

F6. Type or print coordinator phone Required

Select code type from following options: 

• CPT Procedure Code 

• HCPCS Procedure Code 

Required

Type or print applicable procedure code Required

E3. Type or print additional notes or remarks, if any

Part G: Supporting Documentation

G1. Please check and attach the letter of medical necessity from the treating physician Required

G2. Please check and attach the initial and recent clinical evaluation Required

G3. Attach a copy of the treatment protocol Required