Claim for Medical Reimbursement Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0193 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-915 Claim for Medical Reimbursement Form Form and Instruction
OWCP-915 Claim for Medical Reimbursment OWCP-915.pdf www.dol.gov/esa/regs/compliance/owcp/OWCP-915.pdf Form and Instruction
OWCP-915 (Revised Claim for Medical Reimbursement OWCP-915 (draft for 2006 renewal).pdf www.dol.gov/esa/regs/compliance/owcp/OWCP-915.pdf Form and Instruction
FECA 20 CFR 10.802.pdf FECA 20 cfr 10.802 IC Document
EEOICPA 20 CFR 30.702.pdf EEOICPA 20 CFR 30.702 IC Document
BLBA 20 CFR 725.701and 725.705.pdf BLBA 20 CFR 725.701 and 20 CFR 725.705 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Claim for Medical Reimbursement Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.705 20 CFR 10.802 20 CFR 725.701 20 CFR 30.702

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-915	Claim for Medical Reimbursment	OWCP-915.pdf	http://www.dol.gov/esa/regs/compliance/owcp/OWCP-915.pdf	Yes	No	Fillable Printable
Form and Instruction	OWCP-915 (Revised Draft)	Claim for Medical Reimbursement	OWCP-915 (draft for 2006 renewal).pdf	http://www.dol.gov/esa/regs/compliance/owcp/OWCP-915.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)	FR Citation: 67 FR 67

Number of Respondents: 21,396	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	85,584	-50,444	136,028
Annual IC Time Burden (Hours)	14,207	-8,373	22,580
Annual IC Cost Burden (Dollars)	103,557	-60,443	164,000

Documents for IC

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