Uniform Billing Form (OWCP-04)

Uniform Billing Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0019 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-04 Uniform Billing Form (OWCP-04) Form and Instruction
OWCP-04 Uniform Billing Form OWCP-04 Expires 5-31-2019.pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-04.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Uniform Billing Form (OWCP-04)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 725.701 20 CFR 725.704 20 CFR 30.701 20 CFR 725.405 20 CFR 10.801 20 CFR 725.406

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-04	Uniform Billing Form	OWCP-04 Expires 5-31-2019.pdf	http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-04.pdf	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1(FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)	FR Citation: 67 FR 16827

Number of Respondents: 6,315	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 3 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	259,865	37,873	221,992
Annual IC Time Burden (Hours)	29,466	3,963	25,503
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.