Health Insurance Claim Form

OMB 1240-0044

OMB 1240-0044

Requesting address change for Form OWCP-1500. Form OWCP-1500 is used by OWCP and contractor bill payment staff to process bills for medical services provided by medical professionals other than medical services provided by hospitals, pharmacies and certain other medical providers. This information is required to pay health care providers for services rendered to injured employees covered under the Office of Workers' Compensation Programs - administered programs. Appropriate payment cannot be made without documentation of the medical services that were provided by the health care provider that is billing OWCP. The information obtained to complete claims under these programs is used to identify the patient and determine their eligibility. It is also used to decide if the services and supplies received are covered by these programs and to assure that proper payment is made.

The latest form for Health Insurance Claim Form expires 2021-06-30 and can be found here.

All Historical Document Collections
Approved without change
No material or nonsubstantive change to a currently approved collection 2025-03-31
Approved without change
Extension without change of a currently approved collection 2024-06-17
Approved without change
No material or nonsubstantive change to a currently approved collection 2023-12-27
Approved without change
Extension without change of a currently approved collection 2021-05-03
Approved without change
No material or nonsubstantive change to a currently approved collection 2020-10-20
Approved without change
No material or nonsubstantive change to a currently approved collection 2020-02-21
Approved without change
Revision of a currently approved collection 2019-02-13
Approved without change
Revision of a currently approved collection 2018-05-31
Approved without change
No material or nonsubstantive change to a currently approved collection 2018-03-27
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
Extension without change of a currently approved collection 2012-11-14
Approved without change
Revision of a currently approved collection 2010-03-12

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