Owcp 1500 Printable Form

The owcp 1500 or owcp 04 must be attached to this form.

Owcp 1500 printable form. Instructions for completing owcp 1500 health insurance claim form for medical services provided under the federal employees compensation act feca the black lung benefits act blba and the energy employees occupational illness. Office of workers compensation programs owcp 1500 form announcement. Owcp 1500 health insurance claim form. Claim for medical reimbursement form owcp 915 replaces ca 915.

Adobe reader or any alternative for windows or macos are required to access and complete fillable content. Instructions for completing owcp 1500 health insurance claim form for medical services provided under the federal employees compensation act feca the black lung benefits act blba and the energy employees occupational illness. In order to view andor print pdf documents you must have a pdf viewer. Submitted a narrative medical report or a form ca 16 to owcp within the past 10 days you need not submit this form ca 20.

It is the responsibility of the person submitting a claim for reimbursement to obtain a completed owcp 1500 or owcp 04 from the provider. Physicians md do radiologists independent laboratories audiologistsspeech pathologist hearing aid specialists therapists community health departments dme visual services chiropractors home health prostheticsorthotics ambulatory surgical centers home attendant services rural health clinics. Owcps division of federal employees compensation has made a variety of forms available online. Completed in its entirety in the same manner as bills submitted by the provider directly to owcp.

Effective october 1 2015 we will accept paper bills submitted on the revised 1500 claim form version 0615 with icd 9 codes for dates of services prior to 09302015 and icd 10 codes dates of services after to 10012015. The form owcp 1500 health insurance claim form is required to reimburse health care providers for services rendered to injured employees covered under owcp administrative programs and authorized by the federal workers compensation act for injured federal employees is available at the links we have. Download a blank fillable form owcp 1500 health insurance claim form in pdf format just by clicking the download pdf button. Please print or type.

It is highly recommended that you have the most current version click on adobe. These forms are only available in pdf format. Medical travel refund request. The amount paid by the claimant must be indicated.

Owcp requires that medical bills other than hospital bills be submitted on the american medical association health insurance claim form hcfa 1500owcp 1500. Instructions to physician for completing attending physicians.