OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

Medical Travel Refund Request

OMB 1240-0037 ยท DOL/OWCP.

OMB 1240-0037

OWCP must reimburse beneficiaries for travel expenses for covered medical treatment. In order to determine whether amounts requested as travel expenses are appropriate, OWCP must receive certain data elements, including the signature of the physician for medical expenses claimed under the BLBA. Form OWCP-957 is the standard format for the collection of these data elements. The regulations implementing these three statutes allow for the collection of information needed to enable OWCP to determine if reimbursement requests for travel expenses should be paid.

The latest form for Medical Travel Refund Request expires 2026-11-30 and is listed under ICR 202601-1240-002.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form OWCP 957B Medical Travel Refund Request - ExpensesForm and Instruction
Form OWCP-957A Medical Travel Refund Request - MileageForm and Instruction
Form OWCP-957A Medical Travel Refund RequestForm and Instruction
OWCP-957B December 2025 updates.docxSupplementary Document
OWCP-957B December 2025 updates.docx Supplementary Document
OWCP-957A December 2025 updates.docxSupplementary Document
Justification for 1240-0037 Medical Travel Refund Request - Mileage (OWCP-957A).docxJustification for No Material/Nonsubstantive Change
Justification for 1240-0037 Medical Travel Refund Request - Mileage (OWCP-957A).docx Justification for No Material/Nonsubstantive Change
Justification for 1240-0037 Medical Travel Refund Request - Expenses (OWCP-957B) 20260107.docxJustification for No Material/Nonsubstantive Change
Justification for 1240-0037 Medical Travel Refund Request - Expenses (OWCP-957B) 20260107.docx Justification for No Material/Nonsubstantive Change
Medical Travel Request Form (OWCP-957)_exp 20240630.pdfSupplementary Document
Medical Travel Request Form (OWCP-957)_exp 20240630.pdf Supplementary Document
Medical Travel Request Form (OWCP-957B).pdfSupplementary Document
Medical Travel Request Form (OWCP-957B).pdf Supplementary Document
1240-0037 Medical Travel Request Form (OWCP-957A).pdfSupplementary Document
1240-0037 Supporting Statement_FINAL.docxSupporting Statement A
1240-0037 Supporting Statement_FINAL.docxSupporting Statement A
Energy Employees Occupational Illness Compensation Program Act (EEOICPA).pdfSupplementary Document
Energy Employees Occupational Illness Compensation Program Act (EEOICPA).pdf Supplementary Document
Employees Compensation Act.pdfSupplementary Document
Employees Compensation Act.pdf Supplementary Document
Black Lung Benefits Act.pdfSupplementary Document
Black Lung Benefits Act.pdf Supplementary Document
DOL ESA-49 (EEOICPA).docxSupplementary Document
DOL ESA-49 (EEOICPA).docx Supplementary Document
DOL ESA-6 (BLBA).docxSupplementary Document
DOL ESA-6 (BLBA).docx Supplementary Document
DOL GOVT-1 (FECA).docxSupplementary Document
DOL GOVT-1 (FECA).docx Supplementary Document
Medical Travel Refund Request Form and Instruction
Medical Travel Refund Request Form and Instruction
Medical Travel Refund Request Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202601-1240-002 No material or nonsubstantive change to a currently approved collection 2026-01-08 Approved without change
202312-1240-003 No material or nonsubstantive change to a currently approved collection 2024-01-04 Approved without change
202311-1240-004 No material or nonsubstantive change to a currently approved collection 2023-11-20 Approved without change
202308-1240-002 Revision of a currently approved collection 2023-09-25 Approved without change
202206-1240-001 No material or nonsubstantive change to a currently approved collection 2022-06-10 Approved without change
202203-1240-001 No material or nonsubstantive change to a currently approved collection 2022-03-04 Approved without change
202102-1240-002 Extension without change of a currently approved collection 2021-05-03 Approved without change
202008-1240-070 No material or nonsubstantive change to a currently approved collection 2020-10-22 Approved without change
202002-1240-012 No material or nonsubstantive change to a currently approved collection 2020-02-21 Approved without change
201805-1240-003 Revision of a currently approved collection 2018-05-31 Approved without change
201610-1240-002 Extension without change of a currently approved collection 2016-12-28 Approved without change
201306-1240-001 Extension without change of a currently approved collection 2013-10-24 Approved without change
201004-1240-010 Revision of a currently approved collection 2010-08-09 Approved without change
201003-1240-037 Extension without change of a currently approved collection 2010-03-12 Approved without change