Health Insurance Claim Form

ICR 202404-1240-009

OMB: 1240-0044

Federal Form Document

Forms and Documents

Document Name	Status
Form OWCP-1500 Health Insurance Claim Form Form and Instruction	Modified
1240-0044 Supporting Statement _20240611_MN clean.docx Supporting Statement A	2024-06-11
Privacy Act System of Records - FEC.docx Supplementary Document	2020-09-09
20 CFR 725.405 BLBA Supporting Reg.doc Supplementary Document	2012-10-23
20 CFR 30.701 EEOICPA Supporting Reg.doc Supplementary Document	2012-10-23
20 CFR 10.801 FECA - Supporting Reg.doc Supplementary Document	2012-10-23

IC Document Collections

IC ID	Document Title	Status
43805	Health Insurance Claim Form Form and Instruction	Modified