Claim for Medical Reimbursement Form

Forms and Documents

Document Name	Status
Form OWCP-915 Claim for Medical Reimbursement Form Form and Instruction	Modified
ss 1240-0007 (OWCP-915) 2012.docx Supporting Statement A	2012-11-20

IC Document Collections

IC ID	Document Title	Status
38473	Claim for Medical Reimbursement Form Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0007	ICR Reference No: 201209-1240-001
Status: Historical Active	Previous ICR Reference No: 201003-1240-007
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Medical Reimbursement Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/24/2013
	Date Received in OIRA: 12/18/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2016	36 Months From Approved	01/31/2013
Responses	25,872	0	67,296
Time Burden (Hours)	4,294	0	11,171
Cost Burden (Dollars)	42,689	0	103,636

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Abstract: Form OWCP-915 is used to claim reimbursement for out-of-pocket covered medical expenses paid by a beneficiary, and must be accompanied by required billing data elements (prepared by the medical provider) and by proof of payment by the beneficiary.

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Authorizing Statute(s): US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 5 USC 8101 Name of Law: Employees Compensation Act
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 57161	09/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 74881	12/18/2012
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Medical Reimbursement Form	OWCP-915	Claim for Medical Reimbursement

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	25,872	67,296	0	0	-41,424	0
Annual Time Burden (Hours)	4,294	11,171	0	0	-6,877	0
Annual Cost Burden (Dollars)	42,689	103,636	0	0	-60,947	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: As use of the OWCP-915 form decreases, the total number submitted also decreases. For this reason there is a net Burden adjustment decrease of 6,877 hours. While not expected to change respondent burden, this ICR has been characterized as a revision because the agency has reformatted elements of Form OWCP-915 (e.g., replaced an obsolete logo with the DOL Seal, OMB Control Number, additional notice on rights for persons with disabilities, and removed references to the no longer existent Employment Standards Administration). Upon OMB's clearance of this request OWCP will update the form to show the new expiration date.

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Annual Cost to Federal Government: $311,368

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

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 language 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) about:

(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.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/18/2012

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