Information Collection Request
Uniform Billing Form
ICR 202312-1240-005 · OMB 1240-0019 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0019 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form OWCP-04 Uniform Billing Form (OWCP-04) |
Form and Instruction | Modified | Available |
| Form OWCP-04 Uniform Billing Form (OWCP-04) |
Form and Instruction | Modified | Repair queued |
 Justification 1240-0019 Uniform Health Insurance Claim Form (OWCP-04).docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-12-26 | Available |
| Justification 1240-0019 Uniform Health Insurance Claim Form (OWCP-04).docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-12-26 | Repair queued |
 1240-0019 Unifirm Billing Form (OWCP-4) Highlighted Changes.pdf |
Supplementary Document | Uploaded 2023-12-26 | Available |
| 1240-0019 Unifirm Billing Form (OWCP-4) Highlighted Changes.pdf |
Supplementary Document | Uploaded 2023-12-26 | Repair queued |
| ICR 1240-0019 - Supporting Statement A 2.25.22.docx |
Supporting Statement A | Uploaded 2022-02-25 | Available |
| ICR 1240-0019 - Supporting Statement A 2.25.22.docx |
Supporting Statement A | Uploaded 2022-02-25 | Repair queued |
| 20 CFR 725.405, 406, 701 and 705 BLBA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Available |
| 20 CFR 725.405, 406, 701 and 705 BLBA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Repair queued |
| 20 CFR 30.701 EEOICPA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Available |
| 20 CFR 30.701 EEOICPA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Missing upstream |
| 20 CFR 10.801 FECA - Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Available |
| 20 CFR 10.801 FECA - Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 38466 |  Uniform Billing Form (OWCP-04) |
Form and Instruction | Modified | |
| 38466 | Uniform Billing Form (OWCP-04) |
Form and Instruction | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0019 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202112-1240-001 |
| Date Submitted to OIRA | 2023-12-28 |
| Requested Expiration Date | 1969-12-31 |