Sample Health Insurance Claim Form

Public Burden Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection
is 1240-0044. We estimate that it will take an average of seven minutes to complete this collection of information, including time for
reviewing instructions, abstracting information from the patient's records and entering the data onto the form. This time is based on
familiarity with standardized coding structures and prior use of this common form. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, 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 (1240-0044), Washington, DC 20503. DO NOT SEND THE COMPLETED
FORM TO EITHER OF THESE OFFICES.
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.
OMB No. 1240-0044 OWCP-1500 PAGE 4 (Rev. 05-12)
Expires: 01/31/2016
Page 4/4
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Sample Health Insurance Claim Form PDF

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