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September 23, 2008    DOL Home > Find It! By Form > DOL Form   

DOL Form OWCP-915

View ESA-OWCP's Form 1215-0193 Online htm
Agency: ESA-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
OMB Expiration Date: Wednesday, March 31, 2010

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