Medical Travel Refund Request

OMB 1240-0037

Requesting address change to OWCP-957 form. This form is used to request reimbursement for out-of-pocket expenses incurred when traveling to medical providers for covered medical testing or treatment.

The latest form for Medical Travel Refund Request expires 2021-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form OWCP-957A Medical Travel Refund Request Form and Instruction
Form OWCP-957A Medical Travel Refund Request Form and Instruction
Justification for No material Nonsubtantive Change Request - 1240-0037.docx Justification for No Material/Nonsubstantive Change
Justification for No material Nonsubtantive Change Request - 1240-0037.docx Justification for No Material/Nonsubstantive Change
Medical Travel Request Form (OWCP-957)_exp 20240630.pdf Supplementary Document
Medical Travel Request Form (OWCP-957)_exp 20240630.pdf Supplementary Document
Medical Travel Request Form (OWCP-957B).pdf Supplementary Document
Medical Travel Request Form (OWCP-957B).pdf Supplementary Document
1240-0037 Medical Travel Request Form (OWCP-957A).pdf Supplementary Document
1240-0037 Medical Travel Request Form (OWCP-957A).pdf Supplementary Document
1240-0037 Supporting Statement_FINAL.docx Supporting Statement A
1240-0037 Supporting Statement_FINAL.docx Supporting Statement A
Energy Employees Occupational Illness Compensation Program Act (EEOICPA).pdf Supplementary Document
Energy Employees Occupational Illness Compensation Program Act (EEOICPA).pdf Supplementary Document
Employees Compensation Act.pdf Supplementary Document
Employees Compensation Act.pdf Supplementary Document
Black Lung Benefits Act.pdf Supplementary Document
Black Lung Benefits Act.pdf Supplementary Document
DOL ESA-49 (EEOICPA).docx Supplementary Document
DOL ESA-49 (EEOICPA).docx Supplementary Document
DOL ESA-6 (BLBA).docx Supplementary Document
DOL ESA-6 (BLBA).docx Supplementary Document
DOL GOVT-1 (FECA).docx Supplementary Document
DOL GOVT-1 (FECA).docx Supplementary Document
Medical Travel Refund Request Form and Instruction
Medical Travel Refund Request Form and Instruction

All Historical Document Collections

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