Uniform Billing Form (UB-92)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1215-0176 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP/UB-04 Uniform Billing Form (UB-92) Form and Instruction
OWCP/UB-04 Uniform Billing Form OWCP-04 (draft to OMB).pdf owcp.dol.acs-inc.com/portal/pdf/UB-04.pdf Form and Instruction
OWCP/UB-92 Uniform Billing Form Forms and instructions for OWCP-92 (2007 cleared).pdf owcp.dol.asc-inc.com/portal/pdf/UB-92 Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Uniform Billing Form (UB-92)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 10.801 20 CFR 725.406 20 CFR 725.701 20 CFR 725.704 20 CFR 30.701 20 CFR 725.405

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP/UB-04	Uniform Billing Form	OWCP-04 (draft to OMB).pdf	http://owcp.dol.acs-inc.com/portal/pdf/UB-04.pdf	Yes	Yes	Fillable Printable
Form and Instruction	OWCP/UB-92	Uniform Billing Form	Forms and instructions for OWCP-92 (2007 cleared).pdf	http://owcp.dol.asc-inc.com/portal/pdf/UB-92	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1(FECA); DOL/ESA-6 (BLBA); DOL/ESA-49 (EEOICPA)	FR Citation: 67 FR 16827

Number of Respondents: 7,593	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 15 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,372	30,372
Annual IC Time Burden (Hours)	3,544	3,544
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.