Claim for Medical Reimbursement Form

Claim for Medical Reimbursement Form

OMB: 1215-0193

IC ID: 38473

Information Collection (IC) Details

View Information Collection (IC)

Claim for Medical Reimbursement Form
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 725.705 20 CFR 10.802 20 CFR 725.701 20 CFR 30.702

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

Health Health Care Services

DOL/GOVT-1 (FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)  67 FR 67

21,396 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 85,584 0 0 -50,444 0 136,028
Annual IC Time Burden (Hours) 14,207 0 0 -8,373 0 22,580
Annual IC Cost Burden (Dollars) 103,557 0 0 -60,443 0 164,000

Title Document Date Uploaded
FECA 20 cfr 10.802 FECA 20 CFR 10.802.pdf 08/21/2006
EEOICPA 20 CFR 30.702 EEOICPA 20 CFR 30.702.pdf 08/21/2006
BLBA 20 CFR 725.701 and 20 CFR 725.705 BLBA 20 CFR 725.701and 725.705.pdf 08/21/2006
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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