OWCP is requesting an address change to this form. OWCP requires institutional medical providers who provide services to beneficiaries covered under FECA, BLBA, and EEOICPA to bill using a form based on the industry standard, the UB-04. Form OWCP-04 identifies the beneficiary, the type of services provided, the conditions being treated and billed amounts. This information is required by OWCP to enable it to pay providers for covered services.
The latest form for Uniform Billing Form expires 2022-03-31 and can be found here.
Document Name |
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Form and Instruction |
Form and Instruction |
Justification for No Material/Nonsubstantive Change |
Justification for No Material/Nonsubstantive Change |
Supplementary Document |
Supplementary Document |
Supporting Statement A |
Supporting Statement A |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Supplementary Document |
Approved without change |
No material or nonsubstantive change to a currently approved collection | 2023-12-28 | |
Approved without change |
Revision of a currently approved collection | 2022-03-01 | |
Approved without change |
No material or nonsubstantive change to a currently approved collection | 2020-10-20 | |
Approved without change |
Revision of a currently approved collection | 2019-02-09 | |
Approved without change |
Revision of a currently approved collection | 2018-05-31 | |
Comment filed on proposed rule and continue |
Revision of a currently approved collection | 2017-01-10 | |
Approved without change |
Revision of a currently approved collection | 2016-01-29 | |
Comment filed on proposed rule and continue |
Revision of a currently approved collection | 2015-11-18 | |
Approved without change |
Revision of a currently approved collection | 2012-11-27 | |
Approved without change |
Extension without change of a currently approved collection | 2010-03-12 |