Claim for Medical Reimbursement Form

Forms and Documents

Document Name	Status
Form OWCP-915 Claim for Medical Reimbursement Form Form and Instruction	Modified
30-day FRN (1240-0007) published.pdf Supplementary Document	2021-04-23
1240-0007 Supporting Statement (022021) Final.docx Supporting Statement A	2021-04-22
Energy Employees Occupational Illness Compensation Program Act (EEOICPA).pdf Supplementary Document	2021-04-22
Black Lung Benefits Act.pdf Supplementary Document	2021-04-22
Employees Compensation Act.pdf Supplementary Document	2021-04-22
60-day FRN (1240-0007) published.pdf Supplementary Document	2021-04-22

IC Document Collections

IC ID	Document Title	Status
38473	Claim for Medical Reimbursement Form Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0007	ICR Reference No: 202102-1240-004
Status: Received in OIRA	Previous ICR Reference No: 201901-1240-003
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Claim for Medical Reimbursement Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/23/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2021
Responses	34,564	34,564
Time Burden (Hours)	5,738	5,738
Cost Burden (Dollars)	59,450	59,450

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Abstract: Form OWCP-915 is used to claim reimbursement for out-of-pocket covered medical expenses paid by a beneficiary, and must be accompanied by required billing data elements (prepared by the medical provider) and by proof of payment by the beneficiary.

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Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: Employees Compensation Act
   US Code: 30 USC 901 Name of Law: Black Lung Benefits Act
   US Code: 42 USC 7384 Name of Law: Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 8806	02/09/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 21771	04/23/2021
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Claim for Medical Reimbursement Form	OWCP-915	Claim for Medical Reimbursement

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ICR Summary of Burden

	Total Request	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	34,564	34,564	0	0	0	0
Annual Time Burden (Hours)	5,738	5,738	0	0	0	0
Annual Cost Burden (Dollars)	59,450	59,450	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $349,197

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/23/2021

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