U.S. Department of Labor Office of Workers’ Compensation Programs

Publication CM-6

January 2016

Black Lung Medical Benefits:

Questions and Answers about the Federal Black Lung Program
The following material gives you basic information about your medical benefits, but it is neither intended to cover every 

possible exception or special case, nor have the effect of law. Additionally, this information applies only if the Black Lung 

Disability Trust Fund is responsible for your medical benefits. If a private party, such as your employer or its insurance 

carrier, is responsible for your medical benefits, different procedures may apply. You may contact that private party directly 

or the District Office which handles your claim with questions about your medical benefits. STOP HEALTH CARE FRAUD. 

If you suspect any health care fraud, please call our toll-free number 1(800)347-2502. 

Black Lung Medical Benefits:

Frequently Asked Questions about the Federal Black Lung Program

U.S. Department of Labor 

Office of Workers’ Compensation Programs

Division of Coal Mine Workers’ Compensation

Revised January 2016
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Contents

Question Subject Page #

1-3 Black Lung Benefits Identification Card 1-2

4-5 State and Federal Black Lung Benefits 2

6 Social Security Black Lung Benefits 2

7 Covered Medical Services 3

8 Covered Prescription Drugs 3

9-10 Approval for Certain Services 4

11 Non-Covered Medical Services 4

12-16 Direct Billing by Medical Providers 5

17 Billing the Coal Company 6

18 Reimbursing You for Medical Services 6

19 Reimbursing You for Prescription Drugs 7

20 Reimbursing You for Travel 7

21-24 Processing Reimbursement Requests 8-9

25 Change of Address 9

26-27 Keeping Copies for Your Records 9

28 Payments and/or Reimbursements 9

Samples

# Subject Corresponds to Page #

1. Black Lung Benefits Identification Card (Q #1) 1

2. Medical Reimbursement Form, OWCP-915 (Doctor Visit) (Q #18) 10

3. Proof of Payment for Doctor Visit (Q #18) 11

4. Medical Reimbursement Form, OWCP-915 (Prescription

Drugs)

(Q #19) 12

5. Pharmacy Bill Receipt (Q #19) 13

6. Proof of Payment: Computerized Printout Pharmacy

Receipt

(Q #19) 13

7 Medical Travel Refund Request, OWCP-957 (Q #20) 14

8.a. Remittance Voucher (Front of Form) (Q #22) 15

8.b Remittance Voucher (Back of Form) (Q #22) 15
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Introduction

Like all coal miners who qualify for the 

U.S. Department of Labor’s Federal 

Black Lung Program, you are entitled to 

medical benefits to cover the reasonable 

cost of treatment, services or supplies 

for your pneumoconiosis and disability 

(your black lung condition). Spouses, 

family members, and survivors of coal 

miners are not entitled to medical 

benefits. You have the right to seek 

treatment from the medical provider 

(physicians, pharmacies, hospitals, etc.) 

of your choice. Most providers who 

are enrolled in the Federal Black Lung 

Program will bill the Federal Black Lung 

Program directly for you. But if the 

provider is not enrolled in the Federal 

Black Lung Program (or chooses not to 

bill directly), it will be necessary for you 

to pay for the services yourself then file 

with the Federal Black Lung Program on 

your own for reimbursement of these 

out-of-pocket payments.

The questions presented here are those 

most often asked by Black Lung Program 

beneficiaries about:

l The U.S. Department of Labor Black 

Lung Benefits Identification Card 

(medical treatment card); 

l Medical benefits - covered and 

non-covered services; and, 

l Reimbursement for medical care and 

associated travel. 

While this material gives you basic 

information about your medical 

benefits, it is neither intended to cover 

every possible exception or special case, 

nor have the effect of law. Additionally, 

this information applies only if your 

medical benefits are being paid by the 

U.S. Department of Labor. If a private 

party, such as your employer or its 

insurance carrier, is responsible for your 

medical benefits, different procedures 

may apply. You may contact that 

private party directly or write or call 

the U.S. Department of Labor, Division 

of Coal Mine Workers’ Compensation 

(DCMWC) District Office with 

which your claim is filed. For further 

information about special circumstances 

or individual cases, please write or call 

the District Office with which your claim 

is filed. If you are not sure which District 

Office handles your claim, you may find 

out by calling toll-free, Mon.-Fri., 8:00 

a.m.- 8:00 p.m. (ET): 1-800-638-7072.
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What does the Black Lung 

Benefits Identification Card 

look like?

The U.S. Department of Labor Black 

Lung Benefits Identification Card is 

white with a Department of Labor logo, 

and is imprinted with your name, an 

effective date, and possibly an expiration 

date. The red-and-white cards previously issued are obsolete and should be 

destroyed. When medical providers bill 

the Federal Black Lung Program or when 

you submit reimbursement requests, 

your nine-digit Social Security number is 

your identification number. For privacy 

reasons, your Social Security number 

does not appear on your card. However, 

you will need to give your Social Security 

number to your medical treatment providers so they can bill correctly.

Sample 1. Black Lung Benefits 1 Identification Card 

1. This card is the property of the U.S. Government and its counterfeiting, alteration 

or misuse is a violation of Section 499, Title 18, U.S. Code.

2. Carry this card with you at all times and show it to your doctor, clinic or hospital

when you are in need of medical services for your lung condition.

3. The U.S. Department of Labor will pay for medical treatment that is authorized 

under the Black Lung Act. Call 1-800-638-7072 for specific details.

4. All bills should be submitted to the DOL Black Lung Program, P.O. Box 8302, 

London, KY 40742-8302.

5. If found, drop in mailbox. Postmaster, postage guaranteed. Return to: DOL Black 

Lung Program, P.O. Box 8302, London KY 40742-8302.

6. When using the DOL OWCP bill payment website (http://owcp.dol.acs-inc.com/) 

to request an authorization for medical services or to verify eligibility, your doctor 

must use the following Card ID Number: 1234567830. Claimants can also use 

this Card ID Number to access the DOL OWCP bill payment website.

MISUSE OF CARD IS PUNISHABLE BY LAW

Is my personal information 

safe? What does my doctor 

need to know?

Your Social Security number and address 

are not printed on the card, and this is 

information only you will know and will 

need to give to your medical providers. There is a 10-digit number printed 

on the back of the card that is unique to 

you. The purpose of this number is to 

allow the medical providers to access our 

secure web site to get information about 

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your eligibility for benefits and about 

bills they have filed. Your providers will 

probably want to photocopy both sides 

of the card for their records, because 

without the card ID number they will be 

unable to access the secure part of our 

web site.
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When do I use my U.S. 

Department of Labor Black 

Lung Benefits Identification 

Card?

You should present your black lung 

card whenever you seek treatment for 

your lung condition. Showing a medical 

provider your card will identify you as a 

Federal Black Lung Program beneficiary, 

and will help the medical provider determine the proper way to bill for services.

I receive my black lung 

benefits through the U.S. 

Department of Labor around 

the middle of each month, but 

I do not have a black lung card. What 

should I do?

Write or call the DCMWC District Office 

with which your claim is filed. If you are 

not sure which office handles your claim, 

call toll-free, Mon.-Fri., 8:00 a.m.- 8:00 

p.m. (ET), and the operator can tell you 

which District Office to contact: 

1-800-638-7072. 

I was awarded black lung 

benefits by the Federal Black 

Lung Program. I also filed a 

claim with the state where 

I worked as a coal miner and was 

awarded benefits for black lung. Am I 

still entitled to medical coverage under 

the Federal Black Lung Program?

Expenses for the treatment of your black 

lung condition that are not covered by 

the state program may be covered by the 

Federal Black Lung Program. However, 

bills or reimbursement requests must 

first be submitted under the state program which awarded your benefits. 

If your medical providers’ bills or your 

own reimbursement requests are denied 

under your state award, send the bill or 

the reimbursement request and original 

receipts (as discussed in Question 18), 

along with a copy of the denial letter, to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302 

If you have questions, please call the 

DCMWC District Office that handles 

your Federal Black Lung Program claim. 

If you do not have the address or phone 

number of that office, you may get them 

by calling toll-free, Mon.- Fri., 8:00 a.m.-

8:00 p.m. (ET): 1-800-638-7072. 

I have been awarded black 

lung benefits under both the 

Federal Black Lung Program 

and a State Workers’ Compensation Program. Should I have received 

a black lung card?

If you have been awarded benefits for 

your black lung condition under a State 

Workers’ Compensation Program, you 

will NOT receive an identification card 

from the Federal Black Lung Program. 

Expenses for the treatment of your black 

lung condition that are not covered by 

the state program may be covered by 

the Federal Black Lung Program. (See 

Question 5.)

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What costs are covered 

under my Federal Black Lung 

Program medical benefits?

The cost of medical treatment services 

and associated travel for the treatment 

of your black lung condition is covered 

under the Federal Black Lung Benefits 

Act. Payment for medical treatment 

services is subject to a maximum allowable fee. There is no deductible or copayment. Payment for travel is limited to 

reasonable costs.

The following is a list of services that 

MAY be covered when they are performed for the treatment of your black 

lung condition:

l Doctor’s office calls, hospital visits, 

and consultations; 

l Inpatient and outpatient hospital 

charges, including emergency room 

visits for ACUTE black lung related 

conditions, diagnostic laboratory testing and chest x-rays; 

l Federal Black Lung Program 

APPROVED prescription drugs, both 

brand name and generic; 

l Ambulance services limited to transportation to the hospital for emergency ACUTE black lung related care; 

and, 

l Travel to the doctor, hospital, clinic, 

or other medical facility for round 

trips of 200 miles or less. 

The following items require special 

approval:

l The purchase or rental of home 

medical equipment such as oxygen 

systems exceeding $300 (requires 

Certificate of Medical Necessity—See 

Question 10—completed by prescribing physician); 

l Home health care visits for skilled 

nursing (requires Certificate of Medical Necessity completed by prescribing physician); and, 

l Overnight travel, related meals and 

lodging, and/or mileage that exceeds 

200 miles round trip (requires special 

approval from your DCMWC District 

Office). 

What prescription drugs are 

covered? 

Most drugs prescribed by your doctor for the treatment of your black lung 

condition will be covered (brand name 

or generic). However, there are some 

exceptions. In order to be sure a drug is 

covered, you or your pharmacist may call 

toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m. 

(ET): 1-800-638-7072. Your pharmacist will also be able to learn at once if a 

drug is covered if the bill is submitted by 

Point-of-Sale technology.

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Do I need prior approval for 

certain services? 

Yes. Whether you or a medical provider does the billing, your doctor must 

complete the U.S. Department of Labor 

Certificate of Medical Necessity, CM-893 

(CMN), for oxygen and other durable 

medical equipment or skilled nursing 

care at home. 

The doctor should send the completed 

form, with the results of the required

medical tests attached to:

Central Mail Room

Federal Black Lung Program

PO Box 8307

London, KY 40742-8307

CMNs for rental items must be reapproved periodically (a prescription 

for oxygen concentrator, for example). 

All CMNs must have the DOCTOR’S 

ORIGINAL SIGNATURE. Your treating physician’s original signature is the 

ONLY signature acceptable on the CMN. 

You, your physician, and the medical 

provider (if billing the Federal Black 

Lung Program for you) will be notified if 

the CMN has been approved or denied.

Where can my doctor get 

a Certificate of Medical 

Necessity (CMN)?

Your doctor may call the Federal Black 

Lung Program, toll-free, Mon.-Fri., 8:00 

a.m.-8:00 p.m. (ET): 1-800-638-7072.

The form is also available for downloading and printing from our website, at 

http://www.dol.gov/owcp/regs/compliance/cm-893.pdf

What costs are NOT covered 

by my Federal Black Lung 

Program medical benefits?

The following are among the costs NOT 

covered under the Federal Black Lung 

Program:

l Treatment of medical problems NOT 

related to your black lung condition 

—for example, arthritis, diabetes, and 

most heart conditions; 

l Medical treatment for your spouse or 

other family members; 

l Dental or eye care, and X-rays other 

than chest X-rays; 

l Nurse’s aid (non-skilled nursing 

care) services in the home; 

l Home health aides

l Medicine that you can buy without a 

doctor’s prescription; 

l Medicine for problems other than 

your black lung condition; 

l Personal services in the hospital, such 

as TV or telephone; 

l Rental or purchase of an Intermittent 

Positive Pressure Breathing (IPPB) 

machine for home use; 

l Travel to and from your drugstore; 

l Residence costs (room and board) 

for nursing homes or skilled nursing 

facilities; and, 

l Home medical equipment not authorized for coverage under the Federal 

Black Lung Program. 

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What is the best way to get my 

medical bills paid?

WHENEVER POSSIBLE, have your doctor, hospital, pharmacy and other medical providers bill the Federal Black Lung 

Program directly. If they are enrolled in 

the Federal Black Lung Program as providers, the Federal Black Lung Program 

will pay them directly. ALWAYS show 

your Black Lung Benefits Identification 

Card when seeking treatment.

How can a medical provider 

get enrollment and billing 

information from the Federal 

Black Lung Program?

Medical providers not already participating in the Federal Black Lung Program 

may apply for enrollment at any time. 

Those having questions about enrollment 

or billing may call the Federal Black Lung 

Program, toll-free, Mon.-Fri., 8:00 a.m.-

8:00 p.m. (ET): 1-800-638-7072. They 

may also apply online at http://owcp.dol.

acs-inc.com/portal/providerEnrollment.do 

Where should medical 

providers send Black Lung 

related bills?

Answer: ALL Federal Black Lung 

Program medical treatment bills should 

be sent to the following address:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302

Does the medical provider 

need special Department of 

Labor billing forms?

NO. The doctor, clinic, laboratory, 

ambulance and nursing service can bill 

using the standard OWCP-1500 form. 

The pharmacy can bill using the standard 

OWCP-1500 form or the Universal Pharmacy Billing Form. They may also bill 

directly at the Point-of-Sale for most drugs.

The hospital can bill using the UB-04 

form for all inpatient charges and outpatient charges for emergency room, chemotherapy and ambulatory surgical care. 

The OWCP-1500 form should be used 

for other outpatient charges.

What if the medical provider 

wants to bill Medicare, 

UMWA, or other insurance 

carriers instead of the Black 

 Lung Program?

Other insurance carriers should NOT be 

billed first for treatment of your black 

lung condition, because Federal Black 

Lung Program medical benefits represent primary coverage for beneficiaries (unless there is a black lung award 

under a state program. See Question 

5). Medicare and many other insurance 

carriers have a “workers’ compensation 

exclusion clause.” This means that they 

will not pay for treatment of occupational disease, like black lung disease, if 

a patient has medical coverage under a 

workers’ compensation program or the 

Federal Black Lung Program.

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The U.S. Department of Labor 

has notified me that the coal 

company has agreed to pay 

for medical treatment for my 

black lung. How is this handled? 

You will need to ask the coal company 

or its insurance carrier how and where 

both you and medical providers who 

might bill for you should submit medical 

claims. Usually, a medical benefit identification card is NOT issued by the coal 

company. If you need help, you may 

write or telephone the DCMWC District 

Office that handles your claim. 

What if I have to pay the 

medical provider? How do I 

get reimbursed by the Federal 

Black Lung Program?

Present your Black Lung Benefits 

Identification Card to the medical provider whenever you seek treatment for 

your lung condition. A medical provider 

may bill directly, if already enrolled in 

the Federal Black Lung Program. 

If you must pay for the medical services out-of-pocket then you may 

request reimbursement by completing 

the U.S. Department of Labor Medical 

Reimbursement Form, OWCP-915, as 

shown in Sample 2. Up to eight visits 

or services can be listed on this form. 

However, each line used MUST be filled 

in COMPLETELY. Therefore, statements 

such as “see attached” or “see attached 

receipts” are NOT acceptable, when used 

in any of the boxes on the form.

Send the completed Medical 

Reimbursement Form with your itemized paid statements or detailed receipts, 

securely attached, to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302

Your detailed receipts or itemized statements MUST include the following 

information:

l Your full name; 

l Name and address of the medical 

provider; 

l Signature of the medical provider; 

l Description of medical service performed; 

l Date of service; 

l Primary diagnosis or condition treated; 

l Charge for each individual service; 

and, 

l Total amount you paid. 

Receipts and statements must be marked 

“patient paid” or “paid by patient” to 

show specifically who paid the charges.

“Paid” or “paid in full” are NOT acceptable.

A copy of the front and back of your 

canceled check may serve as proof of 

payment ONLY when accompanied by 

an itemized statement or copy of the 

doctor’s ledger record. (See Sample 3.)

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How do I get reimbursed for 

prescription drugs? 

To obtain reimbursement, fill out a 

Medical Reimbursement Form, OWCP915, as shown in Sample 4. Up to nine 

individual prescription drugs may be 

listed on this form. However, each line 

used MUST be filled in COMPLETELY. 

Therefore, statements such as “see 

attached” or “see attached receipts” are 

NOT acceptable when used in any of the 

boxes on the form. 

Send the completed Medical 

Reimbursement Form, along with the 

original pharmacy receipts, securely 

attached, to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302 

These are acceptable receipts: a pharmacy 

bag or sticker, a computerized printout, 

or an itemized listing on the pharmacy’s 

letterhead. These receipts MUST include:

l Your full name, address, and social 

security number; 

l Name of the prescribing doctor; 

l Name and address of the pharmacy; 

l Prescription number; 

l Amount prescribed - mg/ml or cc 

and total ml or cc per bottle for liquid medication, and/or mg per tablet 

and total number of tablets per prescription; 

l Date purchased; 

l Name of each drug; 

l 11-digit National Drug Code (NDC) 

number for the prescribed medication; 

l Charge actually paid for each drug 

less any discount (for example, senior 

citizen, coupon, etc.); a

l A statement, marked “patient paid” 

or “paid by patient,” showing specifically who paid the charges. “Paid” or 

“paid in full” are NOT acceptable. 

(See Sample 5.)

NOTE: If you send an itemized computerized printout, it MUST include all of 

the information already listed, as well as 

the PHARMACIST’S ORIGINAL SIGNATURE.

(See Sample 6.)

Your own itemized listing or cash register receipt is NOT considered proof of 

payment.

A copy of the front and back of your 

canceled check may serve as proof of 

payment, ONLY when accompanied by 

an itemized statement or pharmacist’s 

ledger record.

If you need help getting or completing 

forms for the reimbursement of prescription drugs, please call toll-free, Mon.-

Fri., 8:00 a.m.-8:00 p.m. (ET): 1-800-

638-7072. 

Can I be reimbursed for the cost 

of travel to get medical treatment 

related to my black lung?

Mileage costs for most travel to obtain 

medical treatment for your lung condition may be reimbursed. To get 

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reimbursement, you must complete 

a Medical Travel Refund Request, 

OWCP-957, as shown in Sample 7. You 

may submit up to three trips on each 

form. However, you MUST have the 

MEDICAL PROVIDER, or an authorized representative, complete and SIGN 

block “H” for each visit.

Mail the completed Medical Travel 

Refund Request to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302

LONDON, KY 40742-8302 

NOTE: Overnight travel, related meals 

and lodging, and/or mileage that exceeds 

200 miles round trip requires special 

prior approval from the DCMWC 

District Office. If you are not sure which 

office to contact, call the toll-free number, Mon.-Fri., 8:00 a.m.-8:00 p.m. (ET): 

1-800-638-7072. 

Travel to a pharmacy to pick up prescriptions is NOT covered.

Sample 7. Medical Travel Refund 

Request, OWCP-957 

How much time will my 

reimbursement requests take 

to be processed?

Reimbursement requests which are submitted correctly will be processed by the 

Federal Black Lung Program within 30 

days.

Will I be notified if the 

reimbursement requests I 

send in are going to be paid? 

You will be notified by mail if your 

reimbursement requests will be paid 

or denied, through a form called a 

Remittance Voucher, as shown in 

Samples 8.a. and 8.b. This statement will 

contain the following information:

l The date of service; 

l The amount of your reimbursement 

request; 

l The amount you will be paid; 

l A Remittance Voucher number at 

the top of the form. (This number 

will also appear on your check, if you 

receive a payment, so you can match 

payments with your reimbursement 

requests.); and, 

l A “Message Code” which will explain 

why you were not paid for any portion of the reimbursement request. 

l You will NOT receive a Remittance 

Voucher if your medical provider 

bills the Federal Black Lung Program 

directly.

What will happen if I have not 

submitted my reimbursement 

request forms or receipts 

correctly? Will I still receive a 

 Remittance Voucher?

Any reimbursement request forms and 

receipts that need correction or additional information will be returned to 

you along with a letter explaining what 

is wrong or missing. It is very important 

that you correct and mail back these 

forms and receipts as soon as possible. 

You cannot be paid by the Federal Black 

Lung Program until you submit all 

forms and receipts properly. All corrected reimbursement forms and receipts 

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should be mailed to:

FEDERAL BLACK LUNG PROGRAM 

P.O. BOX 8302 

LONDON, KY 40742-8302

If you need help correcting reimbursement requests which have been returned, 

you may call toll-free, Mon.-Fri., 8:00 

a.m.-8:00 p.m. (ET): 1-800-638-7072.

Will a check come with the 

Remittance Voucher (RV)?

No, the check is always mailed separately. Checks are issued by the U.S. 

Treasury Department. The RV is sent 

from the Federal Black Lung Program 

office where your reimbursement 

requests are processed. The RV will 

usually arrive shortly after your check. 

Please remember to allow enough time 

(10 to 14 days) for both the check and 

the RV to arrive before making inquiries.

If you have questions about your RV, if 

you fail to receive either a check or an 

RV, or if your payment is incorrect and 

requires an adjustment, you may call 

toll-free, Mon.-Fri., 8:00 a.m.-8:00 p.m. 

(ET): 1-800-638-7072.

Whom should I notify if my 

mailing address changes?

Any changes in your mailing address 

should be reported to the DCMWC 

District Office with which your claim 

is filed. If you are not sure which office 

handles your claim, call toll free, Mon.-

Fri., 8:00 a.m.-8:00 p.m. (ET), and the 

operator will tell you whom to contact: 

1-800-638-7072. 

Should I keep copies of the 

bills that I send to the Federal 

Black Lung Program?

YES, if possible. Keeping a copy will 

give you a record of the reimbursement 

requests and receipts you have submitted.

Can I look at my medical bills 

on the internet?

Yes. Black Lung has a secure website. 

Enter: http://owcp.dol.acs-inc.com in 

your browser. Click “Claimant” by 

DCMWC. You will need your SSN and 

your ID number on the back of your 

Member Benefits ID Card (MBIC). 

Payments and/or 

Reimbursements 

The Treasury Department requires that 

all payments and/or reimbursements 

made to you must be electronic. You will 

get your money faster, without the worry 

about lost or stolen checks. You now 

have two options:

1. Have your payment sent directly to 

your bank account or other financial 

institution, or

2. Elect to receive a Direct Express Card, 

which you can use to receive cash and 

make purchases. All payments made to 

you will be added to the amount available on your card.

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Sample 2. Medical Reimbursement Form, OWCP-915 (Doctor Visit)
11

Sample 3. Proof of Payment for Doctor Visit 

l Your full name

l Your address

l Your Social Security Number

l Name and address of medical provider

l Signature of medical provider

l Diagnosis or Condition Treated

l Date of Service

l Description of Service Performed

l Charges for each type of service

l Total amount you paid

l A statement showing specifically who paid the charges (PATIENT PAID or 

l PAID BY PATIENT). “PAID” or “PAID IN FULL” are not acceptable. 

If you need help getting or completing this form, please call toll-free, Mon.- Fri., 

8:00 a.m.-8:00 p.m. (ET): 1-800-638-7072. 
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Sample 4. Medical Reimbursement Form, OWCP-915 

 (Prescription Drugs)
13

Sample 5. Pharmacy Bill Receipt

Prescription Drugs

Receipts can be the pharmacy bag or 

sticker, a computerized printout, or an 

itemized listing on the pharmacy’s letterhead. These receipts must include:

l Your full name, address, and social 

security number

l Name of the prescribing doctor

l Name and address of the pharmacy

l Prescription number

l Amount prescribed-mg/ml or cc and 

total ml or cc per bottle for liquid 

medication, and/or mg per tablet and 

total number of tablets per prescription

l Date purchased

l Name of each drug

l 11-digit National Drug Code (NDC) 

number for the prescribed medication

l Charge actually paid for each drug 

less any discount (e.g., senior citizen 

or coupon)

Sample 6. Proof of Payment: 

 Computerized 

 Printout 

 Pharmacy Receipt

l A statement showing specifically who 

paid the charges (PATIENT PAID 

or PAID BY PATIENT). “PAID” or 

“PAID IN FULL” are not acceptable. 
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Sample 7. Medical Travel Refund Request, OWCP-957 
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Sample 8.a. Remittance Voucher (Front of Form)

Sample 8.b. Remittance Advice (Back of Form)
www.dol.gov

U.S. Department of Labor Office of Workers’ Compensation Programs