Form OWCP-915, Claim for Medical Reimbursement Instructions
This form contains 62 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Claim Details | ||
| OWCP-915[0].Page1[0].RadioButtonList[5]_0 | ComboBox |
Select this option if it applies to your claim. This is part of a set of radio buttons where you need to choose one option.
|
| OWCP-915[0].Page1[0].RadioButtonList[5]_1 | ComboBox |
Select this option if it applies to your claim. This is part of a set of radio buttons where you need to choose one option.
|
| OWCP-915[0].Page1[0].RadioButtonList[6]_0 | ComboBox |
Select this option if it applies to your claim. This is part of a set of radio buttons where you need to choose one option.
|
| OWCP-915[0].Page1[0].RadioButtonList[6]_1 | ComboBox |
Select this option if it applies to your claim. This is part of a set of radio buttons where you need to choose one option.
|
| OWCP-915[0].Page1[0].RadioButtonList[7]_0 | ComboBox |
Select this option if it applies to your claim. This is part of a set of radio buttons where you need to choose one option.
|
| OWCP-915[0].Page1[0].RadioButtonList[7]_1 | ComboBox |
Select this option if it applies to your claim. This is part of a set of radio buttons where you need to choose one option.
|
| Claim Information | ||
| OWCP File Number | Text |
Enter your OWCP (Office of Workers' Compensation Programs) file number.
|
| Form Actions | ||
| Button |
Click this button to print the form.
|
|
| Reset | Button |
Click this button to reset the form to its default state.
|
| General | ||
| Description of change | Text |
Provide a description of the medical service or change for which you are claiming reimbursement.
|
| General Information | ||
| OWCP-915[0].Page1[0].RadioButtonList[0]_0 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[0]_1 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[1]_0 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[1]_1 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[2]_0 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[2]_1 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[3]_0 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[3]_1 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[4]_0 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| OWCP-915[0].Page1[0].RadioButtonList[4]_1 | ComboBox |
Select this option if it applies to the specific question or statement related to your claim. The exact context of this radio button is not provided, so refer to the form for details.
|
| Medical Service Details | ||
| Description of change | Text |
Provide a description of the medical service or change for which you are claiming reimbursement.
|
| Date of service from | Text |
Enter the start date of the medical service for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service for which you are claiming reimbursement.
|
| Description of change | Text |
Provide a description of the medical service or change for which you are claiming reimbursement.
|
| Date of service from | Text |
Enter the start date of the medical service for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service for which you are claiming reimbursement.
|
| Description of change | Text |
Provide a description of the medical service or change for which you are claiming reimbursement.
|
| Date of service from | Text |
Enter the start date of the medical service for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service for which you are claiming reimbursement.
|
| Description of change | Text |
Provide a detailed description of the medical service or treatment for which you are claiming reimbursement.
|
| Date of service from | Text |
Enter the start date of the medical service or treatment for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service or treatment for which you are claiming reimbursement.
|
| Payment Details | ||
| Amount paid by claimant | Text |
Enter the amount you paid out-of-pocket for the medical service.
|
| Amount paid by claimant | Text |
Enter the amount you paid out-of-pocket for the medical service.
|
| Amount paid by claimant | Text |
Enter the amount you paid out-of-pocket for the medical service.
|
| Payment Information | ||
| Amount paid by claimant | Text |
Enter the total amount you paid out-of-pocket for the medical service.
|
| Amount paid by claimant | Text |
Enter the total amount you paid out-of-pocket for the medical service.
|
| Amount paid by claimant | Text |
Enter the total amount you paid out-of-pocket for the medical service.
|
| Amount paid by claimant | Text |
Enter the total amount you paid out-of-pocket for the medical service.
|
| Amount paid by claimant | Text |
Enter the total amount you paid out-of-pocket for the medical service or treatment.
|
| Personal Information | ||
| First | Text |
Enter your first name.
|
| 5622 | Text |
Enter your last name.
|
| M.I | Text |
Enter your middle initial. This field accepts only one character.
|
| Address | Text |
Enter your full mailing address.
|
| City | Text |
Enter the city of your mailing address.
|
| State | ComboBox |
Select the state of your mailing address from the dropdown list.
NC
OH
AK
NJ
CA
TX
PW
CO
IN
ID
OR
FM
GU
ND
IL
AS
MH
PR
VI
NE
KY
NV
MA
AZ
MO
MN
MI
MP
SD
NH
VT
KS
DC
NY
SC
WY
MT
PA
IA
AR
MS
MD
ME
FL
NM
WV
VA
GA
HI
CT
UT
DE
TN
RI
OK
WA
LA
AL
WI
|
| Zip Code | Text |
Enter the ZIP code of your mailing address.
|
| Telephone Number | Text |
Enter your telephone number, including area code.
|
| Provider Information | ||
| cal Supply Company ere expense was incurred. (A separate OWCP-915 ust Name Doctor's Office, Hospital, Pharmacy or Me be filed for each provider) | Text |
Enter the name of the doctor's office, hospital, pharmacy, or medical supply company where the expense was incurred. Note that a separate OWCP-915 form must be filed for each provider.
|
| Reimbursement Details | ||
| Total Reimbursement | Text |
Enter the total amount of reimbursement you are claiming for out-of-pocket medical expenses.
|
| OWCP-915[0].Page1[0].tempTotal[0 | Text |
This field is used to calculate the temporary total of the reimbursement amount. Ensure all relevant expenses are included.
|
| Service Dates | ||
| Date of service from | Text |
Enter the start date of the medical service for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service for which you are claiming reimbursement.
|
| Date of service from | Text |
Enter the start date of the medical service for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service for which you are claiming reimbursement.
|
| Date of service from | Text |
Enter the start date of the medical service for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service for which you are claiming reimbursement.
|
| Date of service from | Text |
Enter the start date of the medical service for which you are claiming reimbursement.
|
| Date of service to | Text |
Enter the end date of the medical service for which you are claiming reimbursement.
|
| Service Description | ||
| Description of change | Text |
Provide a description of the medical service or treatment received.
|
| Description of change | Text |
Provide a description of the medical service or treatment received.
|
| Description of change | Text |
Provide a description of the medical service or treatment received.
|