OWCP’s Division of Coal Mine Workers' Compensation has made a variety of forms available online. These forms are only available in PDF format. In order to view and/or print PDF documents you must have a PDF viewer. It is highly recommended that you have the most current version (click on Adobe Acrobat Reader to download the current version) available on your workstation. Follow these instructions to download PDF files and open them in Adobe Acrobat Reader.

The forms in the list below may be completed manually via the print form option or electronically via the electronic fill/submit option:

Print Form Option

Most of DCMWC’s forms are available online to print and to manually fill and submit. Simply click on the appropriate form and print it using the [Print] button provided near the top of the form. Write or type the required information on the hardcopy and authorize the form, if applicable, with a hand-written signature. Then mail the completed form to our central mailroom at the following address:

U.S. Department of Labor OWCP/DCMWC
P.O. Box 8307
London, KY 40742-8307

IMPORTANT: We are working to have our forms and business reply envelopes updated with the London, KY addresses. Until that is complete, the mailroom currently listed in San Antonio, TX will be forwarding all mail to London, KY. To reduce mail processing delays, please use the London, KY address for mailing, even if the address on the form is San Antonio, TX.

Form-Fill Option

Forms noted with an asterisk (*) may be electronically filled. Simply click on the appropriate form, fill out the form using your computer keyboard and the <TAB> key or your mouse to navigate between form fields. Print the form (use the Print button on or near the top of the form), authorize the form (if applicable provide hand-written signature) and mail the completed form to the DCMWC office you normally send to for this process.

NOTE: When printing these files please remember to use the Adobe Acrobat Reader print icon or the [Print] button on the form, itself, and NOT your browser's print icon on the browser toolbar.

Black Lung Forms



CM-623*Representative Payee Report
CM-623S*Representative Payee Report
CM-787*Physician's/Medical Officer's Statement
CM-893*Certificate of Medical Necessity
CM-908*Notice of Termination, Suspension, Reduction or Increase in Benefit Payments
CM-910*Request To Be Selected As Payee
CM-911*Miner's Claim For Benefits Under The Black Lung Benefits Act
CM-911a*Employment History
CM-912*Survivor's Form For Benefits Under The Black Lung Benefits Act
CM-921Instructions For Completion of Form CM-921
CM-929Report of Changes That May Affect Your Black Lung Benefits
CM-929PReport of Changes That May Affect Your Black Lung Benefits
CM-933Roentgenographic Interpretation
CM-933bRoentgenographic Quality Rereading
CM-936*Authorization For Release Of Medical Information (Black Lung Benefits)
CM-972*Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor
CM-981*Certification by School Official
CM-988*Medical History and Examination for Coal Mine Workers' Pneumoconiosis
CM-1159*Report of Arterial Blood Gas Study
CM-2017*Application or Renewal of Self-Insurance Authority
Instructions for Applying or Renewing Self-Insurance
CM-2017a*Financial Summary for Self-Insured Operators
CM-2017b*Report of Claims Information for Self-Insured Operators
CM-2907Report of Ventilatory Study
CM-2970*Operator Response to Schedule for Submission of Additional Evidence
CM-2970a*Operator Response to Notice of Claim
OWCP-1*Agreement and Undertaking
OWCP-04Uniform Billing Form
OWCP-20*Overpayment Recovery Questionnaire
OWCP-915*Claim For Medical Reimbursement
Form OWCP-915 replaces CA-915
OWCP-957B*Medical Travel Refund Request – Expenses
OWCP-1168Provider Enrollment Form
OWCP-1500*Health Insurance Claim Form