Owcp-915 - Missouri National Guard Page 3
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3PRIVACY ACT STATEMENT
The Privacy Act of 1974, as amended (5 U.S.C. 552a) authorizes OWCP to ask you for information needed in the
administration of the FECA, Black Lung and EEOICPA programs. Authority to collect information is in 5 USC 8101
et seq., 30 USC 901 et seq., 38 USC 613, 42 USC 7384d, E.O. 9397 and E.O. 13179. The information we obtain
with this form is used to identify you and to determine your eligibility for reimbursement. It is also used to decide if
the services and supplies you received are covered by these programs and to ensure that proper payment is made.
There are no penalties for failure to supply information; however, failure to furnish information regarding the
medical service(s) received or the amount charged will prevent payment of the claim. The information may also be
given to other providers of services, carriers, intermediaries, medical review boards, health plans, and other
organizations or Federal agencies, for the effective administration of Federal provisions that require other third
party payers to pay primary to Federal programs, and as otherwise necessary to administer these programs. For
example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor.
Additional disclosures are made through routine uses for information contained in systems of records. See
Department of Labor systems DOL/GOVT-1, DOL/ESA-6 and DOL/ESA-49 published in the Federal Register, Vol.
67, page 16816, Mon. April 8, 2002, or as updated and republished.
ACCOMMODATION STATEMENT
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.
OWCP-915 Page 3 (Rev. 12-07)
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