Information Collection

Uniform Billing Form (OWCP-04)

IC 38466 under ICR 200905-1215-001 · OMB 1215-0176.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form OWcp-04 Uniform Billing Form (OWCP-04)	Form and Instruction
OWcp-04 uNIFORM bILLING fORM OWCP-04 and UB-04 (Sept 2009 draft).pdf	Form and Instruction

IC Title:

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 725.701 20 CFR 725.406 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-04	uNIFORM bILLING fORM	OWCP-04 and UB-04 (Sept 2009 draft).pdf	HTTP:/OWCP.DOL.ACS-INC.COM/PORTAL/PDF/ub-04.PDF	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: 5,481

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 15 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	21,924	-8,448	30,372
Annual IC Time Burden (Hours)	2,558	-986	3,544
Annual IC Cost Burden (Dollars)	0	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.