Information Collection

Uniform Billing Form (OWCP-04)

IC 38466 under ICR 201003-1240-019 · OMB 1240-0019.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0019 can be found here:

Documents and Forms

Document Name Document Type
Form OWcp-04 Uniform Billing Form (OWCP-04) Form and Instruction
OWcp-04 uNIFORM bILLING fORM OWCP-04 and UB-04 (Sept 2009 draft).pdf HTTP:/OWCP.DOL.ACS-INC.COM/PORTAL/PDF/ub-04.PDF Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Uniform Billing Form (OWCP-04)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.801 20 CFR 725.701 20 CFR 725.406 20 CFR 725.704 20 CFR 30.701 20 CFR 725.405

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWcp-04	uNIFORM bILLING fORM	OWCP-04 and UB-04 (Sept 2009 draft).pdf	HTTP:/OWCP.DOL.ACS-INC.COM/PORTAL/PDF/ub-04.PDF	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1(FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)	FR Citation: 67 FR 16827

Number of Respondents: 5,481	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 15 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21,924	-8,448	30,372
Annual IC Time Burden (Hours)	2,558	-986	3,544
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.