Health Insurance Claim Form
ICR 202503-1240-003
OMB: 1240-0044
Federal Form Document
Forms and Documents
Document Name | Status |
|---|---|
Form and Instruction |
Modified |
Form and Instruction |
Modified |
Supplementary Document | 2025-03-28 |
Supplementary Document | 2025-03-28 |
Justification for No Material/Nonsubstantive Change | 2025-03-27 |
Justification for No Material/Nonsubstantive Change | 2025-03-27 |
Supporting Statement A | 2024-06-11 |
Supporting Statement A | 2024-06-11 |
Supplementary Document | 2020-09-09 |
Supplementary Document | 2020-09-09 |
Supplementary Document | 2012-10-23 |
Supplementary Document | 2012-10-23 |
Supplementary Document | 2012-10-23 |
Supplementary Document | 2012-10-23 |
Supplementary Document | 2012-10-23 |
Supplementary Document | 2012-10-23 |
Form OWCP-1500 Health Insurance Claim Form
1240-0044 Health Insurance Claim Form (OWCP- 1500)_Revised.pdf
Justification - 1240-0044 Health Insurance Claim Form (OWCP-1500).docx
20 CFR 725.405 BLBA Supporting Reg.docIC Document Collections
| IC ID | Document Title | Status | |
|---|---|---|---|
| 43805 | Modified | ||
| 43805 | Modified |
Health Insurance Claim FormICR Details
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