Information Collection

Uniform Billing Form (OWCP-04)

IC 38466 under ICR 202501-1240-003 · OMB 1240-0019.

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
Form OWCP-04 Uniform Billing Form Uniform Billing Form (OWCP-04)	Form and Instruction
OWCP-04 Uniform Billing Form 1240-0019 OWCP-04-updated 2025.pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-04.pdf	Form and Instruction
OWCP-04 Uniform Billing Form 1240-0019 OWCP-04-updated 2025.pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-04.pdf	Form and Instruction

IC Title:

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 725.704 20 CFR 30.701 20 CFR 725.405 20 CFR 10.801 20 CFR 725.406 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			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 64529

Number of Respondents: 7,549

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 97 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	198,830	-47,475	246,305
Annual IC Time Burden (Hours)	16,420	-8,264	24,684
Annual IC Cost Burden (Dollars)	1,359,162	1,359,162	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.

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