NOTE TO REVIEWER
Date: March 14, 2018
Request Type: Non-substantive change to a currently approved collection
Employing Agency: Office of Workers’ Compensation Programs (OWCP)
Form Number/Name: OWCP-1500 Health Insurance Claim Form
OMB/Expiration Date: 1240-0044, May 31, 2019
Justification:
We need to make minor change to the form:
We need to process a non - material change the OWCP 1500 form associated instructions, page 3, as well as apply the changes to the fillable form that appears on OWCP.
Place of Service (POS) Codes for Item 24B (page 3 instructions): add following POS codes and descriptions to the existing list.
Update the fillable form Block 24b – Place of Service – add the codes to existing drop down menu.
02 Telehealth
09 Prison
13 Assisted Living
14 Group Home
17 Walk - in Retail Health Clinic
18 Place of Employment/Worksite
49 Independent Clinci
57 Non- residential Substance Abuse Treatment Centr
This change does not impact the content, instructions, or the information being requested.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Thurston, Debra - OWCP |
| File Modified | 0000-00-00 |
| File Created | 2021-01-21 |