Agency:

OWCP

Title:

OWCP-915, Claim for Medical Reimbursement

Form Description:

This form is used to claim reimbursement for out-of-pocket medical expenses pertaining to the treatment of an accepted condition covered by the Federal Employees' Compensation Act, the Black Lung Benefits Act, and the Energy Employees Occupational Illness Compensation Program Act of 2000.

OMB Control Number:

1215-0193

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