Claim for Medical Reimbursement - U.S Department of Labor
U.S Department of Labor
Office of Workers' Compensation Programs
Claim for Medical Reimbursement
Provide all information requested below. DO NOT FILL IN SHADED AREAS. Read the attached
information in order to ensure the submission of all required documentation. Maintain a copy of all
documentation for your records.
OMB No. 1240-0007
Last First M.I.
OWCP File Number
Street/P.O. Box/Apt No.
City State Zip Code
FOR DOL USE ONLY
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,
name of prescription drug, description of
medical product/ supply)
Date of Service (MM/DD/YYYY)
Amount Paid by
Have you included Proof of
Payment for each item?
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)
Claim for Medical Reimbursement - U.S Department of Labor PDF
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