Justification for 1240-0037 'Medical Travel Refund Request - Mileage (OWCP-957A)

Justification

for

Nonsubstantive/No Material Change Request

1240-0037

‘Medical Travel Refund Request - Mileage’ (OWCP-957A)

The Department of Labor’s Office of Workers’ Compensation Programs (OWCP) is the agency responsible for administration of the Federal Employees’ Compensation Act (FECA), 5 U.S.C. 8101, the Black Lung Benefits Act (BLBA), 30 U.S.C. 901 and the Energy Employees’ Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384. These statutes require OWCP to pay for appropriate medical and vocational rehabilitation services provided to beneficiaries.

Form OWCP-957A is used by OWCP and contractor bill processing staff to process reimbursement requests for all covered medical travel expenses, including mileage.

We are requesting to add the following language to the form:

1. Updated instruction:

Added Language after signature instructions: Return this completed claim form to the appropriate program address below.

Division of Federal Employees' Compensation (DFEC)	Division of Energy Employees Occupational Illness Compensation (DEEOIC)
DFEC PO Box 8300 London, KY 40742-8300	DEEOIC PO Box 8304 London, KY 40742-8304 Or submit electronically via Energy Document Portal (EDP)

2.Added Language:

To receive payment, you must have electronic banking information (Electronic Funds Transfer or EFT) on file with the appropriate program to prevent a delay in the processing of your bills. Go To https://www.fiscal.treasury.gov/files/forms/form-1199a.pdf to download and complete the EFT form. Mail your completed claim form to the appropriate program below:

DFEC PO Box 8311 London, KY 40742-8311	DEEOIC PO Box 8306 London, Kentucky 40742-8306 Or submit electronically via Energy Document Portal (EDP)
If you have any questions regarding the completion of the form, please call Toll Free: 1-844-493-1966	If you have any questions regarding the completion of the form, please call Toll Free: 1-866-272-2682

3. Updated the Burden Disclosure Notice to the following:

The public reporting burden for this data collection is estimated to average seven minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. This collection of information is mandatory, as it is needed by OWCP and authorized by 5 USC 8101 et seq., 30 USC 901 et seq., and 42 USC 7384d to collect this information to administer the FECA, BLBA and EEOICPA. The information collected is used to identify the eligibility of the claimant for benefits, and to determine coverage of services provided. Please send comments regarding the burden estimate or any other aspect of this collection of information including suggestions for reducing this burden, and reference OMB control number 1240-0037 to the Office of Workers' Compensation Programs, Department of Labor, Room S3522, 200 Constitution Avenue NW, Washington, DC 20210; and to the Office of Management and Budget, Paperwork Reduction Project (1240-0037), Washington, DC 20503. NOTE: Please do not send your completed form to

4. Updated Privacy Act Statement and the Notice

PRIVACY ACT STATEMENT

We are authorized by OWCP to ask you for information needed in the administration of the FECA, Black Lung and EEOICPA programs. Authority to collect information is in 5 USC 8101 et seq.; 30 USC 901 et seq.; 38 USC 613; E.O. 9397; and 42 USC 7384d, 20 CFR 30.11 and E.O. 13179. The information we obtain to complete claims under these programs is used to identify you and to determine your eligibility. 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. Your response regarding the medical service(s) received or the amount charged is required to receive payment for the claim. See 20 CFR §§ 10.801, 30.701, 725.406, 725.701, and 725.704. Failure to furnish information regarding the medical service(s) received or the amount charged will prevent payment on 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 require other third-party payers to pay primary to Federal programs, and as otherwise necessary to administer these programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures are made through routine uses for information contained in systems of records. See Department of Labor systems DOUGOVT-1, DOUESA-5, DOL/ESA-6, DOU ESA-29, DOL/ESA-30, DOL/ESA-43, DOL/ESA-44, DOUESA-49 and DOL/ESA-50 published in the Federal Register, Vol. 67, page 16816, Mon. April 8, 2002, or as updated and republished. You should be aware that P.L. 100-503, the "Computer Matching and Privacy Protection Act of 1988," permits the government to verify information by way of computer matches.

NOTICE

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 you in the claims process. For example, we will 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 disability. Please contact our office or your claims examiner to ask about this assistance.

The requested changes do not affect the current approved burden for this collection.