Claim for Medical Reimbursement Form

ICR 201612-1240-003

OMB: 1240-0007

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2016-12-15
IC Document Collections
IC ID
Document
Title
Status
38473 Modified
ICR Details
1240-0007 201612-1240-003
Historical Inactive 201606-1240-006
DOL/OWCP
Claim for Medical Reimbursement Form
Revision of a currently approved collection   No
Regular
Comment filed on proposed rule and continue 03/06/2017
Retrieve Notice of Action (NOA) 01/10/2017
In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
  Inventory as of this Action Requested Previously Approved
09/30/2019 09/30/2019 09/30/2019
38,480 0 38,480
6,388 0 6,388
68,879 0 68,879

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

1240-AA11 Proposed rulemaking 82 FR 739 01/04/2017

  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

No
No
The agency received 31,824 responses in FY 2015, fewer than anticipated. This results in a decrease of 1,105 burden hours (6,388 previously approved hours – 5,283 hours = 1,105 hours). Costs also decreased by $14,142 because of the decreased number of responses ($68,879 previously approved – $54,737 = $14,142). In addition, the proposed BLBA rule continues the current information collection requirements but would change where the regulatory authorities are codified. This ICR updates the regulatory citation for the BLBA program’s authority to collect the information.

$326,808
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.
01/10/2017


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