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)
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)].
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.