Home health agencies and other care providers use this form to ask DEEOIC to authorize a service plan for an energy employee: home health care, hospice, nursing home or assisted living. Requests can be initial, re-authorization, amendment or correction. The plan must rest on the treating physician's letter of medical necessity, evidence of a face-to-face exam and a plan of care, which DEEOIC obtains from the physician through Form EE-17B.
The care provider completes Parts A to E. The treating physician supplies the letter of medical necessity, face-to-face exam evidence and plan of care attached in Part E.
Download the current version from the source each time; forms change without notice.
Home Health Care 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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Part E requires a letter of medical necessity, evidence of a face-to-face exam, a plan of care and any records tying the need for care to the accepted conditions. DEEOIC obtains these from the treating physician through Form EE-17B, whose letter must reflect an exam within the past 60 days.
Yes. The instructions say to use dummy Provider ID 999999998 if you are not yet enrolled and to complete provider enrollment through the OWCP medical portal. Enrollment must be approved before the requested services can be authorized.