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

Expires: 01/31/2016

PERSONAL INFORMATION

Name

OWCP File Number

____________________________________________________________

City State Zip Code

FOR DOL USE ONLY

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,

name of prescription drug, description of

medical product/ supply)

Date of Service (MM/DD/YYYY)

Amount Paid by

PERSONAL INFORMATION

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 ____________________________