Uniform Billing Form

ICR 202312-1240-005

OMB: 1240-0019

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0019 can be found here:

2025-04-01 - Extension without change of a currently approved collection

Forms and Documents

Document Name	Status
Form OWCP-04 Uniform Billing Form (OWCP-04) Form and Instruction	Modified
Form OWCP-04 Uniform Billing Form (OWCP-04) Form and Instruction	Modified
Justification 1240-0019 Uniform Health Insurance Claim Form (OWCP-04).docx Justification for No Material/Nonsubstantive Change	2023-12-26
Justification 1240-0019 Uniform Health Insurance Claim Form (OWCP-04).docx Justification for No Material/Nonsubstantive Change	2023-12-26
1240-0019 Unifirm Billing Form (OWCP-4) Highlighted Changes.pdf Supplementary Document	2023-12-26
1240-0019 Unifirm Billing Form (OWCP-4) Highlighted Changes.pdf Supplementary Document	2023-12-26
ICR 1240-0019 - Supporting Statement A 2.25.22.docx Supporting Statement A	2022-02-25
ICR 1240-0019 - Supporting Statement A 2.25.22.docx Supporting Statement A	2022-02-25
20 CFR 725.405, 406, 701 and 705 BLBA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 725.405, 406, 701 and 705 BLBA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 30.701 EEOICPA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 30.701 EEOICPA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 10.801 FECA - Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 10.801 FECA - Supporting Reg.pdf Supplementary Document	2012-11-05

IC Document Collections

IC ID	Document Title	Status
38466	Uniform Billing Form (OWCP-04) Form and Instruction	Modified
38466	Uniform Billing Form (OWCP-04) Form and Instruction	Modified

ICR Details

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