U.S. Department of Labor

Office of Workers' Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

General Medical 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:

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

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

PART D: Service Line Information

D1. Diagnosis Codes: A. B. C. D.

D2. Is this an implant?: Yes No D3. Cost of implant:

Ambulatory Surgery Center (ASC)

Home

Office

Outpatient

D4. Place of Service (Select one)

D5.

From Date To Date

Diagnosis 

Pointer 

A B C D

Code 

Type

Revenue 

Code/NDC

Procedure 

Code Modifier Units/Days Requested

D6. Remarks:

Page 1

Form EE-22 

August 2020
PART E: Supporting Documents

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

denial. See instructions for required documents. Please include claimant’s case ID on each page.

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

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.

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 Line Information

D1. 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

D2. Select an appropriate option if this is an implant 

• Yes 

• No 

Required

D3. Type or print cost of implant Required, if Yes is selected in 

field D2

D4. Select place of surgery from the following options: 

• ASC 

• Home 

• Office 

• Outpatient 

Required

D5. 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 Selects all 

applicable options.

Required

Select code type from following options: 

• CPT Procedure Code 

• HCPCS Procedure Code 

• Revenue Code 

Required

Note: Select Revenue Code type for Outpatient Facility services

Form EE-22 

Page 2 August 2020
Type or print Revenue Code when Code Type is Revenue Code. Type or print NDC when code 

type is HCPCS and Procedure Code is one of the unlisted J- Codes - J3490, J3590, J7999, 

J8499, J8999, J9999

Required

Type or print applicable procedure code (including unlisted J-Code) if code type is CPT or 

HCPCS code. If code type is Revenue Code and procedure code is required for the outpatient 

revenue code, type or print applicable procedure code here 

Required, if code type is CPT or 

HCPCS. OR the outpatient 

Revenue Code requires 

procedure code

Type or print procedure code modifier

Type or print number of units or days requested Required

D6. Type or print additional notes or remarks, if any

Part E: Supporting Documentation

Documents for supporting the need for the service as it relates to the accepted condition(s), such 

as letter of medical necessity, medical records, treatment plan, etc.

Required

Form EE-22 

Page 3 August 2020

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.

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.