View ESA-OWCP's Form 1215-0054 Online
Agency: |
ESA-OWCP |
Title: |
Medical Travel Refund Request |
Form Description: |
The claimant completes the CM 957 to verify out of pocket medical travel expenses and to request reimbursement for these expenses. The information also ensures that the travel expenses are related to the miner’s black lung condition. |
OMB Control Number: |
1215-0054 |
OMB Expiration Date: |
Tuesday, August 31, 2010
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