Health Insurance Claim Form

Documents and Forms

Document Name Document Type
Form OWCP-1500 Health Insurance Claim Form Form and Instruction
OWCP-1500 Health Insurance Claim Form 1240-0044 Health Insurance Claim Form (OWCP-1500).pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf Form and Instruction
OWCP-1500 Health Insurance Claim Form 1240-0044 Health Insurance Claim Form (OWCP-1500).pdf www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Health Insurance Claim Form	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 725.704 20 CFR 725.405 20 CFR 725.715 20 CFR 30.701 20 CFR 725.701 20 CFR 725.406(e)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-1500	Health Insurance Claim Form	1240-0044 Health Insurance Claim Form (OWCP-1500).pdf	http://www.dol.gov/owcp/dfec/regs/compliance/OWCP-1500.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1(FECA); DOL/OWCP-2(BLBA); DOL/OWCP-11(EEOICPA)	FR Citation: 81 FR 25776

Number of Respondents: 43,706	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 67 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,544,050	162,818	3,381,232
Annual IC Time Burden (Hours)	413,473	18,996	394,477
Annual IC Cost Burden (Dollars)	0	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.