HEALTH INSURANCE CLAIM FORM

OMB Control No: 1215-0055	ICR Reference No: 199111-1215-007
Status: Historical Active	Previous ICR Reference No: 199103-1215-001
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: HEALTH INSURANCE CLAIM FORM
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/14/1992
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/21/1991
Terms of Clearance: Pursuant to the Paperwork Reduction Act, this information collection i approved for use through 6/93, subject to the following conditions. OWCP will work with HCFA to determine the feasibility of revising the form immediately to display OMB control numbers assigned to HCFA, DOD, and DOL for use of this form. OWCP will work with the other agencies assure that the next requests for OMB approval indicate placement of all applicable OMB control numbers, that the burden disclosure notice indicates average burden per response for all agencies, and directs public comments to an agency address to be contained within the agency specific instructions. The primary purpose of this form is to reduce administrative burden on providers, suppliers, and others. It may become apparent in implementation that the costs of standardizing the stems of the States, contractors, and private insurers may exceed thes administrative savings. OMB encourages all participating agencies, including DOL, to closely monitor implementation of the form and respo to public comment over the next year. Prior to resubmission of these packages for continued OMB approval, the agencies should critically re-evaluate the cost-effectiveness of this standardization approach.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/1993	06/30/1993	12/31/1991
Responses	634,000	0	877,000
Time Burden (Hours)	157,167	0	150,416
Cost Burden (Dollars)	0	0	0

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Abstract: OWCP 1500 IS A STANDARD FORM USED BY ALL MEDICAL PROVIDERS (EXCEPT PHARMACIES) TO REQUEST PAYMENT FOR FECA AND FBLBA CLAIMANTS' TREATMENT FOR INDUSTRIAL INJURY AND DISEASE.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title Form No. Form Name HEALTH INSURANCE CLAIM FORM OWCP 1500

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ICR Summary of Burden

	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	634,000	877,000	0	0	-243,000	0
Annual Time Burden (Hours)	157,167	150,416	0	0	6,751	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 11/21/1991

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