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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
1215-0055
ICR Reference No:
198407-1215-012
Status:
Historical Active
Previous ICR Reference No:
198309-1215-025
Agency/Subagency:
DOL/ESA
Agency Tracking No:
Title:
HEALTH INSURANCE CLAIM FORM
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
09/13/1984
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/23/1984
Terms of Clearance:
THE RECORDKEEPING REQUIREMENTS FOR THE "HEALTH INSURANCE CLAIM FORM" HAVE BEEN APPROVED WITH THE CONDITION AS AGREED TO BY THE AGENCY THAT THE FORM HCFA 1500 SC (1-84)-OWCP-1500-CHAMPUS 501 AS APPROVED BY THE UNIFORM CLAIM FORM TASK FORCE ON 8/16/83 AND APPROVED BY OMB AS NO. 0938-0008 WITH EXPIRATION DATE 6/30/85 (AS ATTACHED) WILL BE USED.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
07/31/1987
07/31/1987
07/31/1984
Responses
903,000
0
670,000
Time Burden (Hours)
189,500
0
129,667
Cost Burden (Dollars)
0
0
0
Abstract:
THIS IS A STANDARD CLAIM FORM USED BY ALL MEDICAL PROVIDERS EXCEPT HOSPITALS AND PHARMACIES TO REQUEST PAYMENT FOR MEDICAL SERVICES RENDERED TO BOTH FECA AND BLACK LUNG CLAIMANTS.
Authorizing Statute(s):
None
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Federal Register Notices & Comments
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
HEALTH INSURANCE CLAIM FORM
OWCP, 1500A &, OWCP-1500B
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
903,000
670,000
0
233,000
0
0
Annual Time Burden (Hours)
189,500
129,667
0
59,833
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
07/23/1984
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