Claim for Medical Reimbursement Form

OMB 1240-0007

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.

The latest form for Claim for Medical Reimbursement Form expires 2021-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form OWCP-915 Claim for Medical Reimbursement Form Form and Instruction
1240-0007 Supporting Statement_2024__05232024_MN clean.docx Supporting Statement A
Energy Employees Occupational Illness Compensation Program Act (EEOICPA).pdf Supplementary Document
Black Lung Benefits Act.pdf Supplementary Document
Employees Compensation Act.pdf Supplementary Document
Claim for Medical Reimbursement Form Form and Instruction

All Historical Document Collections

202404-1240-007 Approved without change	Extension without change of a currently approved collection	2024-05-30
202102-1240-004 Approved without change	Extension without change of a currently approved collection	2021-04-23
201901-1240-003 Approved without change	Revision of a currently approved collection	2019-02-09
201805-1240-006 Approved without change	Revision of a currently approved collection	2018-05-31
201612-1240-003 Comment filed on proposed rule and continue	Revision of a currently approved collection	2017-01-10
201606-1240-006 Approved without change	Extension without change of a currently approved collection	2016-06-30
201601-1240-006 Improperly submitted and continue	Extension without change of a currently approved collection	2016-01-29
201507-1240-005 Comment filed on proposed rule and continue	Revision of a currently approved collection	2015-11-18
201209-1240-001 Approved without change	Revision of a currently approved collection	2012-12-18
201003-1240-007 Approved without change	Extension without change of a currently approved collection	2010-03-12