| OMB Number | Title |
|---|
| 1240-0060 |
Division of Energy Employees Occupational Illnesses Compensation (DEEOIC) Authorization Request Forms |
| 1240-0059 |
Peace Corps Volunteer Authorization for Examination and/or Treatment |
| 1240-0058 |
Request for Intervention, Longshore and Harbor Workers' Compensation Act |
| 1240-0057 |
Application for Self-Insurance Under the Black Lung Benefits Act |
| 1240-0056 |
Medical Travel Refund Request Form |
| 1240-0055 |
Authorization Request Forms/Certification/Letter of Medical Necessity |
| 1240-0054 |
Disclosure of Medical Evidence |
| 1240-0053 |
Request for Electronic Service of Orders - Waiver of Certified Mail Requirement |
| 1240-0052 |
Contractor Surveys under the Federal EmployeesÂ’ Compensation Act |
| 1240-0051 |
Overpayment Recovery Questionnaire |
| 1240-0050 |
Pharmacy Billing Requirements |
| 1240-0049 |
Representative Fee Request |
| 1240-0048 |
Notice of Issuance of Insurance Policy |
| 1240-0047 |
Request for Employment Information |
| 1240-0046 |
Federal Employees' Compensation Act Medical Reports and Compensation Claims |
| 1240-0045 |
Rehabilitation Plan and Award |
| 1240-0044 |
Health Insurance Claim Form |
| 1240-0043 |
Payment of Compensation Without Award |
| 1240-0042 |
Notice of Controversion of Right to Compensation |
| 1240-0041 |
Notice of Payments |
| 1240-0040 |
Certification of Funeral Expenses |
| 1240-0039 |
Agreement and Undertaking |
| 1240-0038 |
Miner's Claim for Benefits Under the Black Lung Benefits Act and Employment History |
| 1240-0037 |
Medical Travel Refund Request |
| 1240-0036 |
Longshore and Harbor Workers' Compensation Act Pre-Hearing Statement |
| 1240-0035 |
Description of Coal Mine Work and Other Employment |
| 1240-0034 |
Authorization for Release of Medical Information for Black Lung Benefits |
| 1240-0033 |
Coal Mine Operator Response to Schedule for Submission of Additional Evidence and Operator Response to Notice of Claim |
| 1240-0032 |
Request for State or Federal Workers' Compensation Information |
| 1240-0031 |
Certification by School Official |
| 1240-0030 |
Notice of Termination, Suspension, Reduction, or Increase in Benefit Payments |
| 1240-0029 |
Request for Examination and/or Treatment |
| 1240-0028 |
Report of Changes That May Affect Your Black Lung Benefits |
| 1240-0027 |
Survivor's Form for Benefits Under the Black Lung Benefits Act |
| 1240-0026 |
Application for Continuation of Death Benefit for Student |
| 1240-0025 |
Request for Earnings Information Report |
| 1240-0024 |
Certificate of Medical Necessity |
| 1240-0023 |
Claim Adjudication Process for Alleged Presence of Pneumoconiosis |
| 1240-0022 |
Notice of Law Enforcement Officer's Injury or Occupational Disease and Notice of Law Enforcement Officer's Death |
| 1240-0021 |
Provider Enrollment Form |
| 1240-0020 |
Representative Payee Report, Representative Payee Report (Short Form), and Physician's/Medical Officer's Statement |
| 1240-0019 |
Uniform Billing Form |
| 1240-0018 |
Claim for Reimbursement-Assisted Reemployment |
| 1240-0017 |
Death Gratuity |
| 1240-0016 |
Request for Information on Earnings, Dual Benefits, Dependents, and Third Party Settlements |
| 1240-0015 |
Claim for Continuance of Compensation (CA-12) |
| 1240-0014 |
Administration of the Longshore and Harbor Workers' Compensation Act |
| 1240-0013 |
Claim for Compensation by a Dependent Information Reports |
| 1240-0012 |
Rehabilitation Maintenance Certificate |
| 1240-0011 |
Application for Approval of a Representative's Fee in Black Lung Claim Proceedings Conducted by the U.S. Department of Labor |
| 1240-0010 |
Request to be Selected as Payee |
| 1240-0009 |
Notice of Recurrence |
| 1240-0008 |
Rehabilitation Action Report |
| 1240-0007 |
Claim for Medical Reimbursement Form |
| 1240-0006 |
Claim for Reimbursement of Benefit Payments and Claims Expense Under the War Hazards Compensation Act |
| 1240-0005 |
Securing Financial Obligations Under the Longshore and Harbor Workers' Compensation Act and its Extensions |
| 1240-0004 |
Carrier's Report of Issuance of Policy |
| 1240-0003 |
Employer's First Report of Injury or Occupational Disease, Employer's Supplementary Report of Accident or Occupational Illness |
| 1240-0002 |
Energy Employees Occupational Illness Compensation Program Act Forms |
| 1240-0001 |
Statement of Recovery Forms |