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The OWCP 915 form plays a crucial role in the process of seeking medical reimbursement for individuals who have incurred out-of-pocket expenses related to a covered medical condition. This form is utilized by claimants under the Office of Workers' Compensation Programs (OWCP), a division of the U.S. Department of Labor, to facilitate the recovery of funds spent on necessary medical treatments, prescription medications, and medical supplies. Submitting this form requires attention to detail; each provider involved in the care must have a separate OWCP 915 submitted, ensuring organized documentation for the claims process. Important instructions accompany the form, outlining what information is necessary, including personal details, proof of payments, and specific descriptions of the charges incurred. Additionally, the form includes a certification statement confirming the accuracy of the claimed expenses. Understanding the requirements and proper usage of the OWCP 915 can help simplify the reimbursement process, ultimately alleviating some of the financial burdens often felt after a work-related injury or illness. As individuals navigate this process, having a clear grasp of each step can lead to a smoother experience with fewer delays in receiving the funds needed for medical care.

Owcp 915 Example

Claim for Medical Reimbursement

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U.S Department of Labor

Office of Workers' Compensation Programs

Provide all information requested below. DO NOT FILL IN SHADED AREAS. Read the attached

OMB No. 1240-0007

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

 

documentation for your records.

 

 

 

Expires: 05/31/2024

PERSONALINFORMATION

 

 

 

Name

 

 

OWCP File Number

____________________________________________________________

____________________________________

Last

First

M.I.

 

 

 

 

 

 

Address

 

 

Telephone Number

____________________________________________________________

____________________________________

Street/P.O. Box/Apt No.

 

 

 

 

 

 

FOR DOL USE ONLY

 

 

 

____________________________________________________________

 

 

City

 

State Zip Code

 

 

PROVIDER INFORMATION

 

 

 

Name of Doctor’s Office, Hospital, Pharmacy or Medical Supply Company where expense was incurred. (A separate OWCP-915 must be filed for each provider)

Description of Charge (Medical appointment,

Date of Service (MM/DD/YYYY)

Amount Paid by

Have you included Proof of

name of prescription drug, description of

 

 

Claimant

Payment for each item?

medical product/ supply)

 

 

 

 

 

 

 

From

To

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Reimbursement

I certify that the information above 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 statement 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 US Department of Labor, OWCP if necessary for the proper adjudication of this claim.

Signature ____________________________________________________________________ Date ____________________________

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 accepted condition. Form OWCP-915 can be used to seek reimbursement for expenses in regard to medical treatment, prescription medication and medical supplies.

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

•Please print clearly and legibly. Reference your OWCP file number on all documentation. Maintain a copy of the completed OWCP- 915 and supporting documentation for your records.

DOCUMENTATION REQUIRED FOR MEDICAL REIMBURSEMENT

Prescription Medication

1.Completed OWCP-915

2.A paper pharmacy billingform, which must be attached to the OWCP-915 and must include the following information:

a.Name, address and telephone number of pharmacy

b.Pharmacy provider number

c.Prescription number

d.Name of claimant

e.Date of purchase

f.Eleven Digit National Drug Code (NDC#)

g.New prescription or refill number

h.Quantity of medication (e.g. # of pills or ml/cc)

i.Amount paid by employee per medication

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

Medical Expense other than prescription medication

1.Completed OWCP-915

2.Physicians and other health care providers (i.e. physical therapists) must complete Form OWCP-1500. Hospitals and other facilities, such as ambulatory surgical centers, skilled nursing facilities, etc. must submit their bills on Form OWCP-04. Every form must be completed in its entirety in the same manner as bills submitted by 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 claim 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.

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

Travel

Do not use Form OWCP-915 to submit a claim for travel reimbursement. Claims for travel reimbursement should be submitted on Form OWCP-957.

Public Burden Statement

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding the burden estimate or any other aspect to this collection of information, including suggestions for reducing this burden, send them to the Office of Workers’ Compensation Programs, U.S. 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 not required to respond to this information collection unless it displays a currently valid OMB number.

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

PRIVACY ACT STATEMENT

The Privacy Act of 1974, as amended (5 U.S.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 5 USC 8101 et seq., 30 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 identify you and to determine 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; however, failure to furnish information regarding the medical service(s) 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 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 DOL/GOVT-1, DOL/ESA-6 and DOL/ESA-49 published in the Federal Register, Vol. 67, page 16816, Mon. April 8, 2002, or as updated and republished.

ACCOMMODATION 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 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.

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

Get Owcp 915 PDF Form

Form Characteristics

Fact Name Description
Purpose The OWCP-915 form is used to request reimbursement for out-of-pocket medical expenses related to treatment of accepted conditions.
Separate Claims A separate OWCP-915 must be filed for each medical provider where expenses were incurred.
Documentation Required Must include a completed OWCP-915 form, proof of payment, and appropriate billing forms (OWCP-1500 or OWCP-04) where needed.
Travel Claims Do not use Form OWCP-915 for travel reimbursement; instead, file such claims using Form OWCP-957.
Privacy Act The form's collection of information is governed by the Privacy Act of 1974 to ensure confidentiality in handling personal data.
Expiration Date This form is valid until May 31, 2024, after which it may be revised or replaced.

Guidelines on Utilizing Owcp 915

When filling out the OWCP 915 form, it's essential to adhere to the instructions and ensure all information is accurate. After submitting this form, your request for reimbursement will be processed by the Office of Workers' Compensation Programs (OWCP). Keep in mind that any oversight or missing documentation could delay the reimbursement process.

  1. Begin with your personal information: Fill in your full name, including your last name, first name, and middle initial.
  2. Provide your complete address, which includes your street address, city, state, and ZIP code.
  3. Enter your telephone number for contact purposes.
  4. Fill in the provider information: Indicate the name of the doctor’s office, hospital, pharmacy, or medical supply company where the expense occurred. Remember, a separate OWCP-915 must be submitted for each provider.
  5. Describe the charge incurred (e.g., medical appointment, prescription medication) and note the date of service in the appropriate format (MM/DD/YYYY).
  6. Record the total amount paid by you for each item.
  7. Confirm if you have included proof of payment for each item by marking "YES" or "NO."
  8. Complete the reimbursement certification: Read the statement carefully and sign to certify that the information provided is accurate and pertains to expenses paid for the treatment of your covered condition.
  9. Finally, date your signature.

After completing the form, make sure to retain a copy along with all supporting documentation for your records. This can be beneficial for future reference or in case any follow-up is required.

What You Should Know About This Form

What is the OWCP 915 form used for?

The OWCP 915 form is used to request reimbursement for out-of-pocket medical expenses related to treatments for accepted conditions. This includes expenses for medical appointments, prescription medications, and medical supplies. Each provider requires a separate OWCP 915 form submission.

How do I fill out the OWCP 915 form?

To complete the OWCP 915 form, provide your personal information, including your name and OWCP file number. Fill in the provider information for the healthcare professional or facility where you incurred expenses. Clearly detail the charges, including the description of the service, the date of service, and the amount paid. Ensure that you sign and date the form. Lastly, remember to keep a copy of your completed form for your records.

What documentation is required to submit with the OWCP 915 form?

You must attach specific documentation, depending on the type of expense. For prescription medications, include the pharmacy billing form with key details like the date of purchase and proof of payment. For other medical expenses, an OWCP-1500 or OWCP-04 form must be completed by the provider and attached. Ensure all documentation is clear and complete, as missing information may delay processing.

Can I use the OWCP 915 form to claim reimbursement for travel expenses?

No, the OWCP 915 form is not for travel reimbursement. If you need to claim travel expenses, you should use the OWCP 957 form instead. Make sure to submit the correct form to avoid potential delays in processing your reimbursement claim.

What should I do if my claim is denied?

If your claim is denied, review the denial notice carefully to understand the reasons. You can appeal the decision by following the instructions for appeal provided in the notice. It's important to gather any additional documentation or evidence that may support your case before resubmitting your claim.

How long does it take to receive reimbursement after submitting the OWCP 915 form?

The time it takes to process the OWCP 915 form and issue reimbursement can vary. Generally, it may take several weeks to a couple of months depending on the completeness of your submission and the volume of claims being processed. To avoid delays, ensure all information and documentation are accurate and complete when you submit your form.

Common mistakes

When completing the OWCP-915 form for medical reimbursement, many individuals make crucial mistakes that can delay their claims. One common error is failing to provide complete and accurate personal information. The form requests essential details such as your name, address, and OWCP file number. Incomplete or incorrect information can lead to complications in processing the reimbursement request.

Another frequent mistake concerns the documentation attached to the form. Claimants often do not include all required proof of payment. Acceptable forms of proof include cash receipts, canceled checks, or credit card slips. Omitting this documentation may result in the denial of the claim. Each expense claimed must be backed by appropriate documentation to facilitate approval.

Additionally, many people misunderstand the requirement to submit a separate OWCP-915 form for each provider. Failing to adhere to this guideline can cause automatic rejection of claims. It is important to recognize that each medical provider's expenses must be accounted for individually, ensuring clarity in the submission process.

Lastly, some claimants inadvertently ignore the need to complete the form properly by not reading the provided instructions. Ignoring sections or submitting without required details undermines the entire process. Review the form and instructions thoroughly to avoid unnecessary delays and ensure a smoother reimbursement experience.

Documents used along the form

When navigating the reimbursement process with the OWCP-915 form, several other documents may also be required to ensure a smooth and efficient submission. Each of these forms serves a distinct purpose and helps to expedite the review of your medical expenses. Here’s a brief overview of these essential documents.

  • OWCP-1500: This form is used by healthcare providers to bill for services rendered to patients. For claimants, it's crucial because it verifies the medical services provided, enabling OWCP to process reimbursement accurately.
  • OWCP-04: Hospitals and similar facilities use this form for billing. Like the OWCP-1500, it details charges for the medical services provided and must be attached to the OWCP-915 form for reimbursement claims involving hospital services.
  • OWCP-957: For those seeking reimbursement for travel related to medical treatment, this form is used. It specifically addresses travel costs and should not be confused with the medical expense claim forms.
  • Pharmacy Billing Form: This document must accompany your OWCP-915 form when claiming reimbursement for prescription medications. It supplies details such as the pharmacy's information, prescription numbers, and total paid by the claimant.
  • Proof of Payment: Whether it's a receipt, canceled check, or credit card slip, this document is essential. It serves as evidence that you paid for the services or prescription drugs you are claiming reimbursement for.
  • Medical Records: In some cases, you may need to provide medical records that support your claim. These documents can verify the medical necessity of the treatments received, helping to substantiate your reimbursement request.
  • Authorization for Release of Information: Sometimes, you'll need consent forms that allow healthcare providers to share your information with the OWCP. This ensures that all necessary data is available for evaluating your claim.
  • Claimant's Statement: This brief document outlines the claimant's personal details and the circumstances of their medical expenses, ensuring all relevant information is supplied along with the claim.
  • Cover Letter: While not always required, including a cover letter with your submission can clarify your intentions and summarize the enclosed documents, providing context to the claims examiner.

Being organized and prepared with the proper paperwork can significantly impact the effectiveness of your reimbursement claims. Familiarity with these forms and their purposes will help to smooth the claims process and reduce potential delays. Always double-check to ensure that all necessary documents are included with your submissions to the OWCP.

Similar forms

  • OWCP-1500: This form is used by physicians and other healthcare providers to submit claims for medical services. Similar to OWCP-915, it requires details about the service provided, including dates, provider information, and the amount charged. Like the OWCP-915, accurate completion is necessary for processing.
  • OWCP-04: Hospitals and facilities use this form to submit billing for services rendered. OWCP-04 must be attached to the OWCP-915 when seeking reimbursement, ensuring a link between the services received and the claimed expenses, just like the OWCP-1500.
  • OWCP-957: This form is specifically for travel reimbursement claims. While the OWCP-915 focuses on medical expenses, the OWCP-957 serves a similar purpose by detailing travel-related costs, requiring clear documentation to support the reimbursement request.
  • Form SF-95: A standard form used to submit claims for compensation related to personal injury or property damage. It closely parallels the OWCP-915 in requiring comprehensive information and substantiation of the claim, although SF-95 addresses various types of claims beyond medical expenses.
  • Form W-9: This is a request for taxpayer identification information often required by medical providers for reimbursement processing. While focused on tax identification, it shares the importance of accuracy in submissions like the OWCP-915.
  • Form 4506-T: This form allows for the request of tax return transcripts from the IRS. Much like the OWCP-915, it necessitates accurate information and serves as evidence in processing financial claims and helping verify income and expenses.
  • Patient Authorization Form: This is often required by healthcare providers to obtain consent from patients to release medical information. Similar to the certification requirement in the OWCP-915, it establishes the patient's agreement and supports the processing of medical bills.

Dos and Don'ts

When filling out the OWCP-915 form, consider the following guidelines:

  • Do: Complete all required sections of the form carefully.
  • Do: Keep a copy of the submitted OWCP-915 and all supporting documents for your records.
  • Do: Print clearly and legibly to ensure readability.
  • Do: Include proof of payment for each expense you are claiming.
  • Don't: Fill in the shaded areas of the form; leave those sections blank.
  • Don't: Submit multiple claims for the same provider; each provider requires a separate form.
  • Don't: Use this form for travel reimbursements; use Form OWCP-957 instead.
  • Don't: Provide incomplete or illegible documentation, as this may delay processing.

Misconceptions

Here are five misconceptions about the OWCP 915 form, along with explanations for each:

  • The OWCP 915 form can be used for all types of medical expenses. - This form is specifically for reimbursing out-of-pocket medical expenses related to accepted conditions. Expenses for travel should be submitted using Form OWCP-957.
  • Only one OWCP 915 form is needed for multiple providers. - A separate OWCP 915 form must be filled out for each provider. This ensures that each claim is processed correctly and efficiently.
  • Proof of payment is not necessary when submitting the form. - Documentation showing proof of payment is essential. Acceptable forms include cash receipts, canceled checks, or credit card slips. Without this proof, reimbursement may be denied.
  • The form doesn't require additional documentation. - Along with the completed OWCP 915, attached documentation is required. This includes pharmacy billing forms and, for other medical expenses, completed OWCP-1500 or OWCP-04 forms from providers.
  • Submitting the OWCP 915 form guarantees reimbursement. - While the form is necessary for reimbursement, it does not guarantee payment. Claimants must provide accurate information and follow all requirements to ensure a valid claim.

Key takeaways

When using the OWCP 915 form for reimbursement claims, here are some essential points to keep in mind:

  • Complete all sections accurately: Fill out the entire form with current and correct information. Do not leave any required fields blank.
  • Separate submissions required: If expenses were incurred from multiple providers, you must submit a separate OWCP 915 form for each one.
  • Maintain proper documentation: Keep a copy of the completed form along with all supporting documents. This includes proof of payment and any necessary billing forms from the providers.
  • Proof of payment is essential: Ensure you include acceptable proof of payment, such as receipts or credit card slips, to support your claim.
  • Follow the rules on claims: Note that the OWCP 915 form is specifically for medical reimbursements. For travel reimbursement, use Form OWCP 957 instead.

These steps will help streamline the reimbursement process and improve the chances of your claim being processed efficiently.

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