Information Collection

Uniform Health Insurance Claim Form, Health Insurance Claim Form, And Resubmission Turnaround Document

IC 168418 under ICR 199111-1215-010 · OMB 1215-0055.

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Documents and Forms

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Information Collection (IC) Details

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IC Title:	UNIFORM HEALTH INSURANCE CLAIM FORM, HEALTH INSURANCE CLAIM FORM, AND RESUBMISSION TURNAROUND DOCUMENT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	OWCP 1500	No	No
Form	CM 1173	No	No
Form	OWCP 82	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 877,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	877,000	0	877,000
Annual IC Time Burden (Hours)	150,416	-23,850	174,266
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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