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

All Historical Document Collections

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