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View ESA-OWCP's Form 1215-0052 Online 
| Agency: |
ESA-OWCP |
| Title: |
Miner Medical Reimbursement Form |
| Form Description: |
The Miner Medical Reimbursement form is completed by miner beneficiaries when requesting reimbursement for black lung related medical services covered by the program. This form is also used by survivors for reimbursement of medical services provided to the miner, and for expenses incurred in obtaining medical information used in the approval of the survivor’s claim. |
| OMB Control Number: |
1215-0052 |
| OMB Expiration Date: |
Thursday, November 30, 2006
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