Health Insurance Claim Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0055 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-1500 Health Insurance Claim Form Form and Instruction
OWCP-1500 Health Insurance Claim Form OWCP-1500 (NPI version for 2006-2007 revision).pdf www.dol.gov/esa/regs/complainace/owcp/eeoicp/claimsform.htm Form and Instruction
OWCP-1500 Health Insurance Claim Form OWCP-1500 (1215-0055)(electronic 2006 version).pdf www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsform.htm Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Claim 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 30.701 20 CFR 725.405 20 CFR 725.701 20 CFR 725.704 20 CFR 10.801

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-1500	Health Insurance Claim Form	OWCP-1500 (1215-0055)(electronic 2006 version).pdf	http://www.dol.gov/esa/regs/compliance/owcp/eeoicp/claimsform.htm	Yes	No	Fillable Printable
Form and Instruction	OWCP-1500	Health Insurance Claim Form	OWCP-1500 (NPI version for 2006-2007 revision).pdf	http://www.dol.gov/esa/regs/complainace/owcp/eeoicp/claimsform.htm	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 735,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,940,000	2,940,000
Annual IC Time Burden (Hours)	342,908	342,908
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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