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View ESA-OWCP's Form 1215-0193 Online 
| Agency: |
ESA-OWCP |
| Title: |
OWCP-915, Claim for Medical Reimbursement
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| 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.
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| OMB Control Number: |
1215-0193 |
| OMB Expiration Date: |
Wednesday, March 31, 2010
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