OMB control number
Uniform Billing Form
OMB 1240-0019 · DOL/OWCP.
OMB 1240-0019
OWCP requires institutional medical providers who provide services to beneficiaries covered under the Federal Employees’ Compensation Act (FECA), 5 U.S.C. 8101, the Black Lung Benefits Act (BLBA), 30 U.S.C. 901, and the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384, to bill using a form based on the industry standard form approved by the American Hospital Association, the UB-04. Form OWCP-04 identifies the beneficiary, the type of services provided, the conditions being treated and billed amounts. This information is required by OWCP to enable it to pay providers for covered services.
The latest form for Uniform Billing Form expires 2028-05-31 and is listed under ICR 202501-1240-003.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form OWCP-04 Uniform Billing Form | Form and Instruction |
 Form OWCP-04 Uniform Billing Form (OWCP-04) | Form and Instruction |
| PC_202501-1240-003_050125_095355_1.pdf | Public Comments |
| ICR 1240-0019 - Supporting Statement_20250328.docx | Supporting Statement A |
| ICR 1240-0019 - Supporting Statement_20250328.docx | Supporting Statement A |
| 20 CFR 725.405, 406, 701 and 705 BLBA Supporting Reg.pdf | Supplementary Document |
| 20 CFR 725.405, 406, 701 and 705 BLBA Supporting Reg.pdf | Supplementary Document |
| 20 CFR 30.701 EEOICPA Supporting Reg.pdf | Supplementary Document |
| 20 CFR 30.701 EEOICPA Supporting Reg.pdf | Supplementary Document |
| 20 CFR 10.801 FECA - Supporting Reg.pdf | Supplementary Document |
 Uniform Billing Form (OWCP-04) |
Form and Instruction |
| Uniform Billing Form (OWCP-04) |
Form and Instruction |