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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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