83-I Health Insurance Claim Form

PAPERWORK REDUCTION ACT SUBMISSION

Please read the instructions before completing this form. For additional forms or assistance in completing this form, contact your agency's Paperwork Clearance Officer, Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street N.W. Washington, D.C. 20503.
1. Agency/Subagency originating request USDOL/ESA/OWCP	2. OMB control number b. |___| None a. 1215 - 0055
Type of information collection (check one) a. | | New collection b. | | Revision of currently approved collection c. | X | Extension of a currently approved collection d. | | Reinstatement, without change, of a previously approved collection for which approval has expired e. | | Reinstatement, with change, of a previously approved collection for which approval has expired f. | | Existing collection in use without an OMB control number For b-f, note item A2 of Supporting Statement	Type of review requested (check one) a. | X | Regular b. | | Emergency – Approval requested by: / / c. | | Delegated Small entities Will this information collection have a significant economic impact on a substantial number of small entities? | | Yes | X | No Requested expiration date a. | X | Three years from approval date b.| | Other Specify: /
7. Title Health Insurance Claim Form
8. Agency form number(s) (if applicable) OWCP-1500
9. Keywords "Health Insurance; Medical Services"
10. Abstract This information is required to pay health care providers for services rendered to injured employees covered under Office of Workers' Compensation Programs- administered programs. Appropriate payment cannot be made without documentation of the medical services that were provided by the health care provider that is billing OWCP.
11. Affected public (Mark primary with "P" and all others that apply with "X") a. X Individuals or households d. Farms b. P Business or other for-profit e. Federal Government c. X Not-for-profit institutions f. State, Local or Tribal Government	Obligation to respond (Mark primary with "P" and all others that apply with "X") a. Voluntary b. P Required to obtain or retain benefits c. Mandatory
13. Annual reporting and recordkeeping hour burden a . Number of respondents 749,104 b. Total annual responses 2,996,416 1. Percentages of these responses collected electronically 0 % c. Total annual hours requested 359,359 Current OMB inventory 342,908 Difference Explanation of difference 1. Program change ____0_______ 2. Adjustment +16,451	Annual reporting and recordkeeping cost burden (in thousands of dollars) a. Total annualized capital/startup costs 0 b. Total annual costs (O&M) 0 c. Total annualized cost requested 0 d. Current OMB inventory 0 e. Difference _0 f. Explanation of difference 1. Program change ____ 2. Adjustment ____
15. Purpose of information collection (Mark primary with "P" and all others that apply with "X") a. P Application for benefits e. _____Program planning or b. _____ Program evaluation management c. General purpose statistics f. Research d. Audit g. Regulatory or compliance	Frequency of recordkeeping or reporting (check all that apply) a. | | Recordkeeping b. |_____| Third party disclosure c. | X | Reporting 1. | X | On occasion 2. | | Weekly 3. | | Monthly 4. | | Quarterly 5. | | Semi-annually 6. | | Annually 7. | | Biennially 8. | | Other (describe)
17. Statistical methods Does this information collection employ statistical methods? | | Yes | X | No	18. Agency contact (Person who can best answer questions regarding the content of this submission) Name: Patricia M. Wood Phone: 693-1036

OMB 83-1 10/95

19. Certification for Paperwork Reduction Act Submissions On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9. NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8 (b)(3), appear at the end of the instructions. The certification is to be made with reference to those regulatory provisions as set forth in the instructions. The following is a summary of the topics, regarding the proposed collection of information, that the certification covers: (a) It is necessary for the proper performance of agency functions: (b) It avoids unnecessary duplication; (c) It reduces burden on small entities; (d) It uses plain, coherent, and unambiguous terminology that is understandable to respondents; (e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices; (f) It indicates the retention periods for recordkeeping requirements; (g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3); (i) Why the information is being collected; (ii) Use of information; (iii) Burden estimate; (iv) Nature of response (voluntary, required for a benefit, or mandatory); (v) Nature and extent of confidentiality; and, (vi) Need to display currently valid OMB control number; (h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected (see note in Item 19 of the instructions); (i) It uses effective and efficient statistical survey methodology; and, (j) It makes appropriate use of information technology. If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in Item 18 of the Supporting Statement. _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________
Signature of Agency Official	Date
Signature of Senior Official or designee	Date

OMB 83-1 10/95