U.S. Department of Labor

Office of Workers' Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

Home Health Care 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

A3. Date Requested:

A4. Requested By: A5. 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:

C5. Providing care for a family member?: Yes No

C6. If Yes, please provide relationship to the claimant:

PART D: Service Plan Information

D2. Diagnosis Codes: A. B. C. D.

D3.

From Date To Date Diagnosis 

Pointer 

A B C D

Procedure 

Code

Frequency Duration Total units requested

D4. Remarks:

Page 1

Form EE-32 

August 2020

A1. Initial Request Re-Authorization Amendment Correction

A2. Original Authorization Number (For Correction):

D1. Service Type:
Page 2

PART E: 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. See instructions for required documents. Please ensure to include Claimant’s Case ID on each page.

Instructions 

Please read the instructions carefully before completing authorization request. Complete all applicable fields. All Prior Authorization requests 

with supporting documentation must either be faxed with this template or its equivalent or be submitted through the Web Bill Processing Portal 

(https://owcpmed.dol.gov). Please include the DEEOIC Claimant Case ID on all pages. Incomplete requests cannot be processed and will be 

returned.

Part A: Requestor Information

A1. Select an appropriate option for initial, re-authorization, amendment or correction request 

Initial Request – New or first-time request 

Re-Authorization – to request same level of care as the previous request 

Amendment – To request different level of care 

Correction – To update or correct erroneous data elements

Required

A2. Type or print an original authorization number if correction request is being submitted. 

If you don’t have authorization number, provide details about the original authorization, such as 

Claimant’s Case ID, procedure code, date of service, requested units etc. if they are being 

changed in Remarks field

A3. Type or print date on which this template is being completed Required

A4. Type or print name of the person requesting an authorization Required

A5. 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

Part C: Provider Information

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

Note: If you are not yet enrolled in OWCP, use a dummy Provider ID- 999999998 to submit the 

request. Refer to below link to complete the provider enrollment. Provider enrollment needs to be 

approved before the request for service can be authorized. 

https://owcpmed.dol.gov

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.

C5. Select an option if providing care for a family member 

• Yes 

• No 

Required

C6. Type or print relationship to the claimant. Required if “Yes” is 

selected in field C5

Part D: Service Plan Information

D1. Select Service Type from the following options: 

• Assisted Living 

• Home Health Care 

• Hospice 

• Nursing Home 

Required

Form EE-32 

August 2020
Page 3

D2. 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. 

Required

D3. 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

Select applicable procedure code from the following options: 

• T1001 – Nursing assessment/evaluation 

• T1017 – Targeted case management 

• T1019 – Personal care services, per 15 minutes 

• T1020 – Personal care services, per diem 

• T1030 – Nursing care in the home by registered nurse, per diem 

• T1031 – Nursing care in the home by licensed practical nurse, per diem 

• S5126 – Attendant care services, per diem 

• S9122 – Home health aide or certified nurse assistant in home, per hour 

• S9123 – Nursing care in the home by registered nurse, per hour 

• S9124 – Nursing care in the home by licensed practical nurse, per hour 

• S9126 – Hospice care in the home, per diem 

Required

Type or print frequency of service requested. (e.g., 3 times a week) Required

Type or print duration of service requested. (e.g., 4 weeks) Required

Type or print total number of units requested. (e.g., If frequency is 3 times a week, duration is 4 

weeks then total units should be 12)

Required

D4. Type or print additional notes or remarks, if any 

If correction request is being submitted and you don’t have the original authorization number, 

provide details about the original authorization, such as claimant ID, procedure code, date of 

service, requested units etc. if they are being changed

Form EE-32 

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 E: Supporting Documentation

Letter of medical necessity, evidence of face to face exam, plan of care, and any medical 

documentation supporting the need for care as it relates to the accepted condition(s).