Providers treating an energy employee's accepted condition use this request to get DEEOIC prior authorization for procedures, outpatient facility services, implants and drugs. It lists up to four diagnosis codes, the place of service, and service lines coded by CPT, HCPCS or revenue code with units or days requested. Supporting records showing the need for the service must be attached, or the request may be delayed or denied.
The rendering provider, enrolled with OWCP, completes Parts A to E: requestor, claimant, provider, service lines and supporting documents. The claimant does not complete any part.
Download the current version from the source each time; forms change without notice.
General Medical Authorization Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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EE-22 is the general request for procedures, outpatient services and drugs. DEEOIC has separate requests for durable medical equipment (EE-24), rehabilitative therapies (EE-26), transplants (EE-30) and home health care (EE-32), each with fields specific to that kind of service.
DEEOIC wants authorization requests submitted electronically through the OWCP Web Bill Processing Portal and says to fax only if necessary. If you do fax, put the claimant ID on each page so the pages can be matched to the right case.
Item C5 asks whether you are providing care for a family member of the claimant. If you answer yes, item C6 requires your relationship to the claimant. Both items are required, as on the other EEOICPA authorization requests.