Division of Energy Employees Occupational Illness Compensation

Claim Forms & Instructions Administrative Forms & Links
Claimant Medical Reimbursement (OWCP-915)

Medical Travel Refund Request (OWCP-957)

Health Insurance Claim Form (OWCP-1500) | (Instructions)

Uniform Health Insurance Claim Form (OWCP-04) | (Instructions)

ADA Dental Claim Form

How to Submit a Paper Pharmacy Bill

DEEOIC Pharmacy Payer Sheet



Provider Enrollment Application:Downloadable Form

Provider Enrollment Training Presentation:

How to Complete a Provider Enrollment Application Tutorial (Individual)
How to Complete a Provider Enrollment Application Tutorial (Facility)
How to Complete a Provider Enrollment Application Tutorial (Group)
How to Complete an ACH Vendor Payment Form Tutorial

Medical Authorization - Durable Medical Equipment*

Medical Authorization - General Medical/Surgical*

Medical Authorization - Physical Therapy*

Medical Authorization - Home Health

Medical Authorization - Transplant

Helpful Hints

To order Pharmacy Universal Claim Forms, please call Moore-Wallace North America at (800) 635-9500. For more information you may view the NCPDP site.

P2P EDI Information

Conduent EDI Gateway Information

To enroll with EDI, please complete this document: EDI Enrollment Form

EFT Form | (Instructions)

Provider Change of Address

DEEOIC Home Page

DEEOIC FAQ

DEEOIC Contact Info

Adjustment Request