Uniform Billing Form (OWCP-04)

Uniform Billing Form

OMB: 1240-0019

IC ID: 38466

Information Collection (IC) Details

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Uniform Billing Form (OWCP-04)
 
No Modified
 
Required to Obtain or Retain Benefits
 
20 CFR 725.701 20 CFR 725.704 20 CFR 30.701 20 CFR 725.405 20 CFR 10.801 20 CFR 725.406

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OWCP-04 Uniform Billing Form 1240-0019 Unifirm Billing Form (OWCP-4).pdf http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-04.pdf Yes Yes Fillable Printable

Health Health Care Services

DOL/GOVT-1(for FECA); DOL/OWCP-2(for BLBA); DOL/OWCP-11 (for EEOICPA)  81 FR 64529

16,276 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   97 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 246,305 0 0 0 0 246,305
Annual IC Time Burden (Hours) 24,684 0 0 0 0 24,684
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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