Health Insurance Claim Form

HEALTH INSURANCE CLAIM FORM

OMB: 1215-0055

IC ID: 121975

Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details

View Information Collection (IC)

HEALTH INSURANCE CLAIM FORM
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form OWCP 1500 No No
Form OWCP 82 No No


    

756,170 0
   
Individuals or Households
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 756,170 0 122,170 0 0 634,000
Annual IC Time Burden (Hours) 146,986 0 -10,181 0 0 157,167
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

© 2024 OMB.report | Privacy Policy