Transcription of Claim for Medical Reimbursement U.S Department of ... - DOL
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Claim for Medical Reimbursement U.S Department of ... - DOL
Claim for Medical Reimbursement 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: 05/31/2024. PERSONAL. PERSONALINFORMATION. INFORMATION. Name OWCP File Number _____ _____. Last First Address Telephone Number _____ _____. 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). Description of Charge ( Medical appointment , Date of Service (MM/DD/YYYY) Amount Paid by Have you included Proof of name of prescription drug, description of Claimant Payment for each item?)
information in order to ensure the submission of all required documentation. Maintain a copy of all documentation for your records. ... (Medical appointment, name of prescription drug, description of medical product/ supply) Date of Service (MM/DD/YYYY) ... 915 and supporting documentation for your records. Prescription Medication . 1 ...
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