U.S. Department of Labor

Office of Workers' Compensation Programs 

Division of Energy Employees Occupational 

Illness Compensation

Rehabilitative Therapies 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: Therapy Plan Information

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

D3.

From Date To Date Diagnosis 

Pointer 

A B C D

Code 

Type

Procedure 

Code

# of units 

per 

procedure/ 

visit

Frequency Duration Total units 

requested

D4. Remarks:

Page 1

Form EE-26 

August 2020

A1. Initial Request Re-Authorization Amendment Correction

A2. Original Authorization Number (For Correction):

Home Facility Office Outpatient

D1. Place of Service (Select one)
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

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 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: Therapy Plan Information

D1. Select place of service from the following options: 

• Home 

• Facility 

• Office 

• Outpatient 

Required

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

Form EE-26 

August 2020
Page 3

Select code type from following options: 

• CPT Procedure Code 

• HCPCS Procedure Code 

Required

Type or print applicable procedure code Required

Type or print number of units per visit or procedure 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 number of total units requested. Multiply # of Units Requested (per procedure) x Required

Frequency Requested x Duration = Total Units Requested. E.g. # of unit per visit is 2, if 

frequency is 3 times a week, duration is 4 weeks, then total unit should be 24.

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

Form EE-26 

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

Therapy Evaluation, Letter of Medical Necessity (LMN). Evidence of Face to Face exam, and 

any medical documentation supporting the need for therapy as it relates to the accepted 

condition(s). If services will be provided in the home, LMN must indicate whether or not claimant 

is homebound.

Required