Claim for Medical Reimbursement Form

Claim for Medical Reimbursement Form

OMB: 1215-0193

IC ID: 38473

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Information Collection (IC) Details

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Claim for Medical Reimbursement 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-915 No No


    

34,007 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 136,028 0 1,120 0 0 134,908
Annual IC Time Burden (Hours) 22,580 0 186 0 0 22,394
Annual IC Cost Burden (Dollars) 164,000 0 1,000 0 0 163,000

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