Owcp-957 - Medical Travel Refund Request Form - U.s. Department Of Labor
Download a blank fillable Owcp-957 - Medical Travel Refund Request Form - U.s. Department Of Labor in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Owcp-957 - Medical Travel Refund Request Form - U.s. Department Of Labor with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2U.S. Department of Labor
Medical Travel Refund Request
Office of Workers' Compensation Programs
Reset
Print
OMB No. 1240-0037
NOTE: This report is authorized by the Federal Employees' Compensation Act (5 USC 8103(a)), the Black Lung Benefits Act (30
Expires: 11/30/2013
USC 901; 20 CFR 725.406 and 725.701) and the Energy Employees Occupational Illness Compensation Program Act of 2000,
(42 USC 7384 and 20 CFR 30.701). While you are not required to respond, this information is required to obtain reimbursement for
travel expenses. The method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974 and
OMB Circ. 108. This form should be used for medically related travel covered by the Federal Employees' Compensation Act, the
Black Lung Benefits Act and the Energy Employees Occupational Illness Compensation Program Act of 2000.
2. Case/Claim Number:
1. Claimant's Name (Last, First, Mi.):
3. Payee's Name if different from claimant's name (last, first, mi.): (See instruction no. 3 on the back of form)
4. Claimant's/Payee's Address (Street/RFD, City, State, Zip Code):
1. See reverse side of form for complete instructions and attachment of receipts.
Special Instructions:
2. Physician's signature or facsimile is REQUIRED by BLACK LUNG for verification of each service date and type.
f. Total expense/cost
DOL USE ONLY
FOR BLACK LUNG USE ONLY
5a. Date of Travel:
TOS/Procedure Code
h. To be completed by Physician:
Taxi $
b.
One-way
Round Trip
(Mark one box only)
Bus/Train
$
Care Rendered
c. Travel From:
d. Travel To:
Tolls/Pkg
Treatment for Black Lung
Hospital
Hospital
Lodging
Not Black Lung Related
Office/clinic
Office/clinic
Meals
Lab
Lab
Determine, Test for Black Lung
Other
Home
Home
Diagnosis
(Specify)
e. Medical Facility Name and Address
g. Private Auto Only
(Signature of Physician)
Miles traveled
Total $
(Date Care Rendered)
f. Total expense/cost
DOL USE ONLY
FOR BLACK LUNG USE ONLY
6a. Date of Travel:
TOS/Procedure Code
h. To be completed by Physician:
Taxi $
b.
One-way
Round Trip
(Mark one box only)
Bus/Train
$
Care Rendered
c. Travel From:
d. Travel To:
Tolls/Pkg
Treatment for Black Lung
Hospital
Hospital
Lodging
Not Black Lung Related
Office/clinic
Office/clinic
Meals
Lab
Lab
Determine, Test for Black Lung
Other
Home
Home
Diagnosis
(Specify)
e. Medical Facility Name and Address
g. Private Auto Only
(Signature of Physician)
Miles traveled
Total $
(Date Care Rendered)
f. Total expense/cost
DOL USE ONLY
FOR BLACK LUNG USE ONLY
7a. Date of Travel:
TOS/Procedure Code
h. To be completed by Physician:
Taxi $
b.
One-way
Round Trip
(Mark one box only)
Bus/Train
$
Care Rendered
c. Travel From:
d. Travel To:
Tolls/Pkg
Treatment for Black Lung
Hospital
Hospital
Lodging
Not Black Lung Related
Office/clinic
Office/clinic
Meals
Lab
Lab
Determine, Test for Black Lung
Other
Home
Home
Diagnosis
(Specify)
e. Medical Facility Name and Address
g. Private Auto Only
(Signature of Physician)
Miles traveled
Total $
(Date Care Rendered)
8. Payee's Certification: I hereby certify that the information given by me on and in connection with this form is true and correct to the best of my
knowledge and belief. I am aware that any person who knowingly makes any false statement or misrepresentation to obtain reimbursement from
OWCP is subject to civil penalties and/or criminal prosecution.
Date:
Claimant's/Payee's Signature:
Form OWCP-957
Rev. Aug 2003
ADVERTISEMENT
0 votes
Related Articles
Related forms
Certification Of Qualifying Exigency For Military Family Leave (family And Medical Leave Act) - Adopted From U.s. Department Of Labor Form Wh-384
Business
Related Categories
Parent category: Legal