In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
Inventory as of this Action
Requested
Previously Approved
01/31/2016
36 Months From Approved
09/30/2016
25,872
0
25,872
4,294
0
4,294
42,689
0
42,689
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
As use of the OWCP-915 form increases, the total number submitted also increases. For this reason there is a net Burden adjustment increase of 2,094 hours.
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.
Form OWCP-915 Claim for Medical Reimbursement Form
Supporting Statement 1240-0007 (OWCP-915) 2015.docx
Claim for Medical Reimbursement Form