Claim for Medical Reimbursement Form

ICR 201606-1240-006

OMB: 1240-0007

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2016-06-29
IC Document Collections
IC ID
Document
Title
Status
38473 Modified
ICR Details
1240-0007 201606-1240-006
Historical Active 201209-1240-001
DOL/OWCP
Claim for Medical Reimbursement Form
Extension without change of a currently approved collection   No
Regular
Approved without change 09/13/2016
Retrieve Notice of Action (NOA) 06/30/2016
  Inventory as of this Action Requested Previously Approved
09/30/2019 36 Months From Approved 09/30/2016
38,480 0 25,872
6,388 0 4,294
68,879 0 42,689

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.

US Code: 5 USC 8101 Name of Law: Employees Compensation Act
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
  
None

Not associated with rulemaking

  80 FR 49279 08/17/2015
81 FR 8994 02/23/2016
No

1
IC Title Form No. Form Name
Claim for Medical Reimbursement Form OWCP-915 Claim for Medical Reimbursement

  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 38,480 25,872 0 0 12,608 0
Annual Time Burden (Hours) 6,388 4,294 0 0 2,094 0
Annual Cost Burden (Dollars) 68,879 42,689 0 0 26,190 0
No
No
The change in burden stems from updated information. The agency, on average, received 38,480 responses in each of the past three years. Multiplied by the time per response these results in an increase of 2,094 burden hours. (38,480 responses x .166 response time = 6,388 burden hours. Previous approval 4,294 hours. 6,388 hours – 4,294 hours = 2,094 hours). In addition, other costs increased by $26,190, because of the increased responses. [(38,480 responses x $1.79 Postage and envelope = $68,879) ($68,879 – $42,689 previously approved = $26,190)].

$325,947
No
No
No
No
No
Uncollected
Yoon Ferguson 202 693-0701 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
06/30/2016


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