UNIFORM BILLING CLAIM FORM

ICR 198501-1215-003

OMB: 1215-0142

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
122264 Migrated
ICR Details
1215-0142 198501-1215-003
Historical Active 198210-1215-001
DOL/ESA
UNIFORM BILLING CLAIM FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 04/01/1985
Retrieve Notice of Action (NOA) 01/31/1985
The proposed paperwork is approved with the changes in burden hour estimate as agreed to by the Department on 4/01/85.
  Inventory as of this Action Requested Previously Approved
10/31/1987 10/31/1987
149,000 0 0
43,817 0 0
0 0 0

THE UNIFORM BILLING CLAIM FORM WILL ENABLE INSTITUTIONAL MEDICAL PROVIDERS OF HEALTH SERVICES SUCH AS HOSPITALS AND CLINICS TO BILL OWC FOR PAYMENT FOR INPATIENT CARE PROVIDED TO CLAIMANTS AS BENEFICIARIES.

None
None


No

1
IC Title Form No. Form Name
UNIFORM BILLING CLAIM FORM OWCP-82A &, OWCP-82B

  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 149,000 0 0 0 149,000 0
Annual Time Burden (Hours) 43,817 0 0 0 43,817 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
01/31/1985


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