Health Insurance Claim Form

ICR 200506-1215-006

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
38450 Migrated
ICR Details
1215-0055 200506-1215-006
Historical Active 200309-1215-002
DOL/ESA
Health Insurance Claim Form
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/29/2005
Retrieve Notice of Action (NOA) 06/29/2005
  Inventory as of this Action Requested Previously Approved
11/30/2006 11/30/2006 11/30/2006
2,141,216 0 2,133,708
249,688 0 248,812
0 0 0

This information is required to pay health care providers for services rendered to injured employees covered under Office of Workers' Compensation Programs administered programs. Appropriate payment cannot be made without documentation of the medical services that were provided by the health care provider that is billing OWCP.

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 2,141,216 2,133,708 0 7,508 0 0
Annual Time Burden (Hours) 249,688 248,812 0 876 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
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.
06/29/2005


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