Health Insurance Claim Form

OMB 1215-0055

Latest Forms, Documents, and Supporting Material

Document Name
Form OWCP-1500 Health Insurance Claim Form Form
83-I - Health Insurance Claim Form (1215-0055)(2009 clearance).doc Supplementary Document
Supporting Stmt for 1215-0055 (7 17 2009) final.doc Supporting Statement A
20 CFR 725.405 BLBA Supporting Reg.(2009 clearance).doc Supplementary Document
20 CFR 30.701 EEOICPA Supporting Reg.(2009 clearance).doc Supplementary Document
20 CFR 10.801 FECA - Supporting Reg.(2009 clearance).doc Supplementary Document
Health Insurance Claim Form Form

All Historical Document Collections

200907-1215-001 Approved without change	Revision of a currently approved collection	2009-08-24
200610-1215-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-10-31
200607-1215-001 Approved without change	Extension without change of a currently approved collection	2006-07-10
200506-1215-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2005-06-29
200309-1215-002 Approved without change	Extension without change of a currently approved collection	2003-09-26
200108-1215-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2001-08-03
200009-1215-001 Approved without change	Extension without change of a currently approved collection	2000-09-21
199709-1215-001 Approved without change	Extension without change of a currently approved collection	1997-09-24
199608-1215-007 Approved without change	No material or nonsubstantive change to a currently approved collection	1996-08-15
199409-1215-004 Approved without change	Revision of a currently approved collection	1994-09-01
199407-1215-004 Approved with change	No material or nonsubstantive change to a currently approved collection	1994-07-13
199307-1215-002 Approved without change	Revision of a currently approved collection	1993-07-22
199306-1215-006 Approved with change	No material or nonsubstantive change to a currently approved collection	1993-06-29
199111-1215-010 Approved with change	No material or nonsubstantive change to a currently approved collection	1991-11-19
199111-1215-007 Approved without change	Revision of a currently approved collection	1991-11-21
199103-1215-001 Approved without change	Revision of a currently approved collection	1991-03-14
199008-1215-001 Approved without change	Revision of a currently approved collection	1990-08-01
198710-1215-002 Approved without change	Revision of a currently approved collection	1987-10-19
198407-1215-012 Approved without change	Revision of a currently approved collection	1984-07-23
198309-1215-025 Approved with change	No material or nonsubstantive change to a currently approved collection	1983-09-06
198206-1215-001 Approved without change	Revision of a currently approved collection	1982-06-21
197808-1215-003 Approved without change	Revision of a currently approved collection	1978-08-17
197806-1215-004 Approved without change	Extension without change of a currently approved collection	1978-06-29