HEALTH INSURANCE CLAIM FORM

ICR 199306-1215-006

OMB: 1215-0055

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
168419 Migrated
ICR Details
1215-0055 199306-1215-006
Historical Active 199111-1215-010
DOL/ESA
HEALTH INSURANCE CLAIM FORM
No material or nonsubstantive change to a currently approved collection   No
Emergency 06/29/1993
Approved with change 06/29/1993
Retrieve Notice of Action (NOA) 06/29/1993
  Inventory as of this Action Requested Previously Approved
09/30/1993 09/30/1993 06/30/1993
634,000 0 634,000
157,167 0 157,167
0 0 0

OWCP 1500 IS A STANDARD FORM USED BY ALL MEDICAL PROVIDERS (EXCEPT PHARMACIES) TO REQUEST PAYMENT FOR FECA AND FBLBA CLAIMANTS' TREATMENT FOR INDUSTRIAL INJURY AND DISEASE.

None
None


No

1
IC Title Form No. Form Name
HEALTH INSURANCE CLAIM FORM OWCP 1500

  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 634,000 634,000 0 0 0 0
Annual Time Burden (Hours) 157,167 157,167 0 0 0 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.
06/29/1993


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