Claim for Medical Reimbursement Form

Forms and Documents

Document	Type	Status	Availability
Form OWCP-915 Claim for Medical Reimbursement Form	Form and Instruction	Modified	Available
SS 1215-0193 December 2006.doc	Supporting Statement A	Uploaded 2006-12-18	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
38473	Claim for Medical Reimbursement Form	Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0193	ICR Reference No: 200608-1215-006
Status: Historical Active	Previous ICR Reference No: 200506-1215-009
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Claim for Medical Reimbursement Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/28/2007
	Date Received in OIRA: 01/03/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2010	36 Months From Approved	03/31/2007
Responses	85,584	0	136,028
Time Burden (Hours)	14,207	0	22,580
Cost Burden (Dollars)	103,557	0	164,000

---

Abstract: Form OWCP-915 is used to claim reimbursement for out-of-pocket covered medical expenses paid by a beneficiary, and must be accompanied by required billing data elements (prepared by the medical provider) and by proof of payment by the beneficiary.

---

Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: Employees Compensation Act
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 46924	08/15/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 78224	12/28/2006
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Medical Reimbursement Form	OWCP-915, OWCP-915 (Revised Draft)	Claim for Medical Reimbursment ,   Claim for Medical Reimbursement

---

ICR Summary of Burden

	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	85,584	136,028	0	0	-50,444	0
Annual Time Burden (Hours)	14,207	22,580	0	0	-8,373	0
Annual Cost Burden (Dollars)	103,557	164,000	0	0	-60,443	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Due to the continuing decline in the number of BLBA beneficiaries currently in the program, and the increase in medical providers billing OWCP directly for medical services rather than billing their patients, who then would have to seek reimbursement from OWCP using Form OWCP-915, shows an adjustment change of -8,372 burden hours and -$60,444 in operational and maintenance costs.

---

Annual Cost to Federal Government: $812,703

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 01/03/2007

---