Information Collection

Uniform Billing Form (UB-92)

IC 38466 under ICR 200701-1215-007 · OMB 1215-0176.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0176 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWCP/UB-04 Uniform Billing Form (UB-92)	Form and Instruction
OWCP/UB-04 Uniform Billing Form OWCP-04 (draft to OMB).pdf owcp.dol.acs-inc.com/portal/pdf/UB-04.pdf	Form and Instruction
OWCP/UB-92 Uniform Billing Form Forms and instructions for OWCP-92 (2007 cleared).pdf owcp.dol.asc-inc.com/portal/pdf/UB-92	Form and Instruction

IC Title:

Uniform Billing Form (UB-92)

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 10.801 20 CFR 725.406 20 CFR 725.701 20 CFR 725.704 20 CFR 30.701 20 CFR 725.405

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP/UB-04	Uniform Billing Form	OWCP-04 (draft to OMB).pdf	http://owcp.dol.acs-inc.com/portal/pdf/UB-04.pdf	Yes	Yes	Fillable Printable
Form and Instruction	OWCP/UB-92	Uniform Billing Form	Forms and instructions for OWCP-92 (2007 cleared).pdf	http://owcp.dol.asc-inc.com/portal/pdf/UB-92	Yes	Yes	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 16827

Number of Respondents: 7,593

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30,372	30,372
Annual IC Time Burden (Hours)	3,544	3,544
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.