Uniform Billing Form

ICR 200506-1215-012

OMB: 1215-0176

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
38466 Migrated
ICR Details
1215-0176 200506-1215-012
Historical Active 200310-1215-003
DOL/ESA
Uniform Billing 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
01/31/2007 01/31/2007 01/31/2007
231,224 0 230,716
26,984 0 26,925
0 0 0

OWCP requires institutional medical providers who provide services to beneficiaries covered under FECA, BLBA and EEOICPA to bill using a form based on the industry standard, the UB-92. Form OWCP-92 identifies the benficiary , the type of services provided, the conditions being treated and billed amounts. This information is required by OWCP to enable it to pay providers for covered services.

None
None


No

1
IC Title Form No. Form Name
Uniform Billing Form OWCP-92

  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 231,224 230,716 0 508 0 0
Annual Time Burden (Hours) 26,984 26,925 0 59 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


© 2024 OMB.report | Privacy Policy