Claim 915 Can It Be Uploaded to Owcp

U.Due south Department of Labor

Office of Workers' Compensation Programs

Claim for Medical Reimbursement

Provide all information requested beneath. DO NOT FILL IN SHADED AREAS. Read the fastened

information in order to ensure the submission of all required documentation. Maintain a copy of all

documentation for your records.

OMB No. 1240-0007

Expires: 06/30/2021

PERSONAL INFORMATION

Name

____________________________________________________________

Last First Chiliad.I.

OWCP File Number

____________________________________

Address

____________________________________________________________

Street/P.O. Box/Apt No.

____________________________________________________________

City State Zip Lawmaking

Telephone Number

____________________________________

FOR DOL USE ONLY

PROVIDER Information

Name of Doctor's Office, Hospital, Chemist's or Medical Supply Company where expense was incurred. (A divide OWCP-915 must

be filed for each provider)

Description of Charge (Medical appointment,

name of prescription drug, description of

medical product/ supply)

Engagement of Service (MM/DD/YYYY)

From To

Corporeality Paid by

Claimant

Have you included Proof of

Payment for each item?

PERSONAL INFORMATION

YES NO

Full Reimbursement

I certify that the information in a higher place is correct and that the reimbursement requested is for expenses paid by me for the treatment of my

covered condition. I am aware that any person who knowingly makes any false argument or misrepresentation to obtain reimbursement

from OWCP is subject to civil penalties and/or criminal prosecution.

I authorize any provider named above to release information to the U.s.a. Department of Labor, OWCP if necessary for the proper

adjudication of this claim.

Signature ____________________________________________________________________ Appointment ____________________________

OWCP-915 (Rev. 12-07)

INSTRUCTIONS FOR USE OF FORM OWCP-915

• This form is to be used to seek reimbursement for out of pocket medical expenses pertaining to the treatment of an accustomed

condition. Course OWCP-915 can be used to seek reimbursement for expenses in regard to medical handling, prescription medication

and medical supplies.

• Please submit a split reimbursement claim for each provider where an out of pocket expense was incurred.

• Please print conspicuously and legibly. Reference your OWCP file number on all documentation. Maintain a copy of the completed OWCP-

915 and supporting documentation for your records.

Prescription Medication

1. Completed OWCP-915

two. A paper chemist's shop billingform, which must be fastened to the OWCP-915 and must include the following information:

a. Name, address and telephone number of pharmacy

b. Chemist's provider number

c. Prescription number

d. Name of claimant

eastward. Date of purchase

f. 11 Digit National Drug Code (NDC#)

chiliad. New prescription or refill number

h. Quantity of medication (east.thousand. # of pills or ml/cc)

i. Corporeality paid by employee per medication

3. Proof of payment (tin can include cash receipt, cancelled bank check or credit carte slip)

Medical Expense other than prescription medication

i. Completed OWCP-915

2. Physicians and other wellness intendance providers (i.east. concrete therapists) must complete Grade OWCP-1500. Hospitals and other facilities,

such equally convalescent surgical centers, skilled nursing facilities, etc. must submit their bills on Form OWCP-04. Every class must exist

completed in its entirety in the same way as bills submitted past the provider directly to OWCP. The amount paid by the claimant

must be indicated. The OWCP-1500 or OWCP-04 must be attached to this form. It is the responsibility of the person submitting

a merits for reimbursement to obtain a completed OWCP-1500 or OWCP-04 from the provider rendering service. Without a fully

completed OWCP-1500 or OWCP-04, the OWCP is not able to process a reimbursement.

iii. Proof of payment (can include cash receipt, cancelled bank check or credit card slip)

Travel

Do not use Class OWCP-915 to submit a claim for travel reimbursement. Claims for travel reimbursement should exist submitted on Form

OWCP-957.

DOCUMENTATION REQUIRED FOR MEDICAL REIMBURSEMENT

Public Burden Statement

Public reporting burden for this drove of information is estimated to average 10 minutes per response, including time for reviewing

instructions, searching existing information sources, gathering and maintaining the data needed, and completing and reviewing the drove of

information. If you have any comments regarding the burden estimate or any other attribute to this collection of information, including

suggestions for reducing this burden, send them to the Role of Workers' Bounty Programs, U.Due south. Department of Labor, Room

S3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. Do not submit the completed claim form to this address. Persons are

non required to answer to this information collection unless it displays a currently valid OMB number.

OWCP-915 Page 2 (Rev. 12-07)

PRIVACY ACT Argument

The Privacy Act of 1974, every bit amended (5 U.Due south.C. 552a) authorizes OWCP to ask you for information needed in the

administration of the FECA, Black Lung and EEOICPA programs. Authority to collect information is in five USC 8101

et seq., thirty USC 901 et seq., 38 USC 613, 42 USC 7384d, E.O. 9397 and E.O. 13179. The information we obtain

with this form is used to place you and to decide your eligibility for reimbursement. It is also used to decide if

the services and supplies you received are covered by these programs and to ensure that proper payment is made.

There are no penalties for failure to supply information; nonetheless, failure to furnish information regarding the

medical service(south) received or the amount charged will prevent payment of the claim. The information may also be

given to other providers of services, carriers, intermediaries, medical review boards, health plans, and other

organizations or Federal agencies, for the effective administration of Federal provisions that crave other 3rd

party payers to pay primary to Federal programs, and as otherwise necessary to administer these programs. For

instance, it may exist necessary to disembalm information almost the benefits you have used to a hospital or physician.

Additional disclosures are fabricated through routine uses for information contained in systems of records. See

Department of Labor systems DOL/GOVT-1, DOL/ESA-six and DOL/ESA-49 published in the Federal Annals, Vol.

67, page 16816, Monday. April eight, 2002, or as updated and republished.

Adaptation STATEMENT

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you

the right to receive help from OWCP in the form of communication assistance, accommodation and modification to

aid yous in the claims process. For instance, nosotros volition provide you with copies of documents in alternate formats,

communication services such as sign language interpretation, or other kinds of adjustments or changes to account

for the limitations of your inability. Please contact our function or your claims examiner to enquire most this aid.

OWCP-915 Folio 3 (Rev. 12-07)

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