Information Collection

Uniform Billing Form (OWCP-04)

IC 38466 under ICR 201812-1240-003 · OMB 1240-0019.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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

Information Collection Instruments:

table that charts list of 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(for FECA); DOL/OWCP-2(for BLBA); DOL/OWCP-11 (for EEOICPA)

FR Citation: 81 FR 25766

Number of Respondents: 6,315

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 3 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	259,865	259,865
Annual IC Time Burden (Hours)	29,466	29,466
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.