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Uniform Billing Form (UB-92)

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

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Form and Instruction
Form and Instruction
Form and Instruction
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Uniform Billing Form (UB-92)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 10.801 20 CFR 725.406 20 CFR 725.701 20 CFR 725.704 20 CFR 30.701 20 CFR 725.405

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

Health Health Care Services

DOL/GOVT-1(FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)  67 FR 16827

7,593 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   15 %

  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 30,372 0 0 0 0 30,372
Annual IC Time Burden (Hours) 3,544 0 0 0 0 3,544
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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