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⚠️ Notice: This information collection may be referencing outdated material.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 725.405 20 CFR 10.801 20 CFR 725.406 20 CFR 725.704 20 CFR 30.701 20 CFR 725.701

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(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 %

	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

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.