Owcp-915 - Missouri National Guard
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1
2
3Claim for Medical Reimbursement
U.S Department of Labor
Office of Workers' Compensation Programs
Reset
Print
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: 01/31/2016
PERSONAL INFORMATION
PERSONAL INFORMATION
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)
Have you included Proof of
Description of Charge (Medical appointment,
Date of Service (MM/DD/YYYY)
Amount Paid by
Payment for each item?
name of prescription drug, description of
Claimant
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)
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