View ESA-OWCP's Form 1215-0055 Online
Agency: |
ESA-OWCP |
Title: |
OWCP-1500, Health Insurance Claim Form |
Form Description: |
OWCP-1500, Health Insurance Claim Form: This information is required to reimburse health care providers for services rendered to injured employees covered under OWCP-administrative programs. |
OMB Control Number: |
1215-0055 |
OMB Expiration Date: |
Saturday, October 31, 2009
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