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Federal forms, ICRs, and supporting documents

Information Collection Request

UNIFORM HEALTH INSURANCE CLAIM FORM, HEALTH INSURANCE CLAIM FORM, AND RESUBMISSION TURNAROUND DOCUMENT

ICR 199103-1215-001 · OMB 1215-0055 · Historical Active

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IC Document Collections
IC IDCollectionTypeStatusForm
121972 UNIFORM HEALTH INSURANCE CLAIM FORM, HEALTH INSURANCE CLAIM FORM, AND RESUBMISSION TURNAROUND DOCUMENT Form Migrated
ICR Details
1215-0055 199103-1215-001
Historical Active 199008-1215-001
DOL/ESA
UNIFORM HEALTH INSURANCE CLAIM FORM, HEALTH INSURANCE CLAIM FORM, AND RESUBMISSION TURNAROUND DOCUMENT
Revision of a currently approved collection   No
Regular
Approved without change 06/17/1991
Retrieve Notice of Action (NOA) 03/14/1991
This form and its associated instructions are approved through Decembe 1991, consistent with the approval we have granted to the HCFA 1500. Because this is a shared form, it shall display the current OMB approv numbers for all three agencies. Agencies shall include the public burd disclosure statement required at 5 CFR 1320.21 at the beginning of the form's instructions, and shall include a notice on the form which refe to the existence of this statement. We note that the unit burden estimates that the agencies have made for this form vary greatly, even though the required data does not. Prior to their next submissions, DO HHS, and DOL should work together to develop a common burden estimate for completing those portions of the form common to all. The next submissions shall discuss the computation of the common estimate and a deviations that may exist.
  Inventory as of this Action Requested Previously Approved
12/31/1991 12/31/1991 10/31/1991
877,000 0 877,000
174,266 0 174,266
0 0 0
OWCP 1500 IS A STANDARD FORM USED BY ALL MEDICAL PROVIDERS (EXCEPT PHARMACIES) TO REQUEST PAYMENT FOR FEC AND BL CLAIMANTS. FORM HAS BEE REVISED FOR SIMPLIFICATION. OWCP 82 IS USED BY PROVIDERS TO BILL OWCP FOR INPATIENT CARE PROVIDED TO CLAIMANTS. RTD COLLECTS MISSING INFORMATION FOR THE BL PORTION OF OWCP 82 AND OWCP 1500.
None
None
No
1
IC Title Form No. Form Name
UNIFORM HEALTH INSURANCE CLAIM FORM, HEALTH INSURANCE CLAIM FORM, AND RESUBMISSION TURNAROUND DOCUMENT OWCP 1500, CM 1173, OWCP 82
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 877,000 877,000 0 0 0 0
Annual Time Burden (Hours) 174,266 174,266 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/14/1991