Uniform Health Insurance Claim Form -- UB-92

ICR 199710-1215-004

OMB: 1215-0176

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
13886 Migrated
ICR Details
1215-0176 199710-1215-004
Historical Active 199412-1215-002
DOL/ESA
Uniform Health Insurance Claim Form -- UB-92
Extension without change of a currently approved collection   No
Regular
Approved without change 12/09/1997
Retrieve Notice of Action (NOA) 10/23/1997
  Inventory as of this Action Requested Previously Approved
12/31/2000 12/31/2000 12/31/1997
157,393 0 143,462
34,076 0 33,513
0 0 0

OWCP requests hospitals providing medical services to beneficiaries covered under FECA and FBLBA to bill on the standard form UB-92. This form identifies the injured worker, the naturel of services provided, the conditions being treated, and billed amounts. This information is required by OWCP to enable reimbursement for covered services.

None
None


No

1
IC Title Form No. Form Name
Uniform Health Insurance Claim Form -- UB-92 UB-92

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 157,393 143,462 0 0 13,931 0
Annual Time Burden (Hours) 34,076 33,513 0 0 563 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/23/1997


© 2024 OMB.report | Privacy Policy