OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Claim for Medical Reimbursement Form

ICR 201003-1240-007 · OMB 1240-0007 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form OWCP-915 Claim for Medical Reimbursement Form Form and Instruction Modified Available
Supporting stmt 1215-0193 2009 final.doc Supporting Statement A Uploaded 2009-10-30 Available
IC Document Collections
IC IDCollectionTypeStatusForm
38473 Claim for Medical Reimbursement Form Form and Instruction Modified
ICR Details
1240-0007 201003-1240-007
Historical Active 200608-1215-006
DOL/OWCP
Claim for Medical Reimbursement Form
Extension without change of a currently approved collection   No
Regular
Approved without change 03/12/2010
Retrieve Notice of Action (NOA) 03/12/2010
  Inventory as of this Action Requested Previously Approved
12/31/2012 36 Months From Approved
67,296 0 85,584
11,171 0 14,207
103,636 0 103,557
Form OWCP-915 is used to claim reimbursement for out-of-pocket covered medical expenses paid by a beneficiary, and must be accompanied by required billing data elements (prepared by the medical provider) and by proof of payment by the beneficiary.
US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 5 USC 8101 Name of Law: Employees Compensation Act
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  
None
Not associated with rulemaking
  74 FR 38474 08/03/2009
74 FR 59243 11/17/2009
No
1
IC Title Form No. Form Name
Claim for Medical Reimbursement Form OWCP-915 Claim for Medical Reimbursement
  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 67,296 85,584 0 0 -18,288 0
Annual Time Burden (Hours) 11,171 14,207 0 0 -3,036 0
Annual Cost Burden (Dollars) 103,636 103,557 0 0 79 0
No
No
Due to the continuing decline in the number of BLBA beneficiaries currently in the program, the increase in the number of EEOICPA beneficiaries in the program, and the increase in the number of medical providers billing OWCP directly for medical services in the FECA progrram rather than billing their patients, who then would have to seek reimbursement from OWCP using Form OWCP-915, there is a change of -3036 burdens hours. There is no change reported for the operational and maintenance costs.
$459,492
No
No
Uncollected
Uncollected
No
Uncollected
Sheldon Turley 202-693-5337 [email protected]
  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.
11/17/2009