Claim for Medical Reimbursement Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OWCP-915 Claim for Medical Reimbursement	Form and Instruction	Modified	Repair queued
Form OWCP-915 Claim for Medical Reimbursement Form	Form and Instruction	Modified	Repair queued
1240-0007 Supporting Statement_2024__05232024_MN clean.docx	Supporting Statement A	Uploaded 2024-05-23	Repair queued
Energy Employees Occupational Illness Compensation Program Act (EEOICPA).pdf	Supplementary Document	Uploaded 2021-04-22	Repair queued
Black Lung Benefits Act.pdf	Supplementary Document	Uploaded 2021-04-22	Repair queued
Employees Compensation Act.pdf	Supplementary Document	Uploaded 2021-04-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38473	Claim for Medical Reimbursement Form	Form and Instruction	Modified	Claim for Medical Reimbursement
38473	Claim for Medical Reimbursement Form	Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0007	ICR Reference No: 202404-1240-007
Status: Historical Active	Previous ICR Reference No: 202102-1240-004
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Medical Reimbursement Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/02/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/30/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2027	36 Months From Approved	07/31/2024
Responses	54,067	0	34,564
Time Burden (Hours)	9,029	0	5,738
Cost Burden (Dollars)	1,184	0	59,450

---

Abstract: Form OWCP-915 is used to claim reimbursement for out-of-pocket covered medical expenses paid by a beneficiary, and must be accompanied by required billing data elements (prepared by the medical provider) and by proof of payment by the beneficiary.

---

Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: Employees Compensation Act
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 9869	02/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 46909	05/30/2024
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Claim for Medical Reimbursement Form	OWCP-915	Claim for Medical Reimbursement

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	54,067	34,564	0	0	19,503	0
Annual Time Burden (Hours)	9,029	5,738	0	0	3,291	0
Annual Cost Burden (Dollars)	1,184	59,450	0	0	-58,266	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Burden hours have increased from 5,738 to 9,029 due to the increase in claim submissions. The decrease in the operations and maintenances costs is due to the capability of submitting this form electronically.

---

Annual Cost to Federal Government: $327,505

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 05/30/2024

---