HEALTH INSURANCE CLAIM FORM 

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE

MEDICARE 

(Medicare#)

MEDICAID 

(Medicaid#)

TRICARE 

(ID#/DoD#)

CHAMPVA 

(Member ID#)

GROUP HEALTH 

PLAN (ID#)

FECA BLK 

LUNG (ID#)

OTHER 

(ID#)

1. 1a. INSURED I.D. NUMBER (For Program in Item 1)

2. PATIENT'S NAME (Last, First, Middle Initial) 3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last, First, Middle Initial)

M F

5. PATIENT'S ADDRESS (Street, City, State, Zip)

TELEPHONE (Include Area Code):

7. INSURED'S ADDRESS (Street, City, State, Zip)

TELEPHONE (Include Area Code):

6. PATIENT RELATIONSHIP TO INSURED

Self Spouse Child Other

9. OTHER INSURED'S NAME (Last, First, Middle Initial)

a. OTHER INSURED POLICY OR GROUP NUMBER

8. RESERVED FOR NUCC USE

b. RESERVED FOR NUCC USE

c. RESERVED FOR NUCC USE

d. PATIENT'S PLAN OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC)

Yes No

a. EMPLOYMENT? (Current or Previous)

Yes No

b. AUTO ACCIDENT?

Yes No

c. OTHER ACCIDENT?

PLACE (State)

10. PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER

SEX

M F

a. INSURED'S DATE OF BIRTH

b. OTHER CLAIM ID (Designated by NUCC)

c. INSURANCE PLAN NAME OR PROGRAM NAME

Yes No

d. IS THERE ANOTHER HEALTH BENEFIT PLAN? 

If yes, complete items 9, 9a, and 9d.

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 

12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to 

process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. 

 

SIGNED _________________________________________________ DATE

13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE 

I authorize payment of medical benefits to the undersigned physician 

or supplier for services described below.. 

 

SIGNED _______________________________________________

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)

QUAL.

15. OTHER DATE

QUAL. FROM:

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

TO:

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

17b. NPI FROM:

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

TO:

19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

Yes No

20. OUTSIDE LAB? $ CHARGES

A.

E.

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24e)

I.

B.

F.

J.

C.

G.

K.

D.

H.

L.

ICD Ind. 22. RESUBMISSION CODE ORIGINAL REF. NO.

23. PRIOR AUTHORIZATION NUMBER

24. A. DATE(S) OF SERVICE

From To

B. 

PLACE OF 

SERVICE 

C. 

 

EMG

D. PROCEDURES, SERVICES, OR SUPPLIES 

(Explain Unusual Circumstances)

CPT/HCPSCS MODIFIER

E. 

DIAGNOSIS 

 POINTER (A-L)

F. 

 

 $ CHARGES

G. 

DAYS OR 

 UNITS

H. 

EPSOT 

Family 

Plan

I. 

ID 

QUAL.

J. 

RENDERING 

PROVIDER NPI #

NPI

NPI

NPI

NPI

NPI

NPI

25. FEDERAL TAX I.D. NUMBER

SSN EIN

26. PATIENT'S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? 

(For govt. claims, see back)

Yes No

28. TOTAL CHARGE

$

29. AMOUNT PAID

$

30. Rsvd for NUCC Use

31. SIGNATURE OF PHYSICIAN OR SUPPLIER 

 INCLUDING DEGREES OR CREDENTIALS 

 (I certify that the statements on the reverse 

 apply to this bill and are made a part thereof.) 

 

 

SIGNED __________________ DATE

32. SERVICE FACILITY LOCATION INFORMATION

a. b.

33. BILLING PROVIDER INFO & PH # 

a. b.

PATIENT AND INSURED INFORMATION PHYSICIAN OR SUPPLIER INFORMATION

NUCC instruction Manual available at www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB-093B-1197 FORM CMS-1500 (06-15)

OMB No. 1240-0044 

Expires: 06/30/2024
Instructions for Completing OWCP-1500 Health Insurance Claim Form For Medical Services Provided Under the FEDERAL EMPLOYEES' 

COMPENSATION ACT (FECA), the BLACK LUNG BENEFITS ACT (BLBA), and the ENERGY EMPLOYEES OCCUPATIONAL ILLNESS 

COMPENSATION PROGRAM ACT of 2000 (EEOICPA) 

GENERAL INFORMATION-FECA AND EEOICPA CLAIMANTS: Claims filed under FECA (5 USC 8101 et seq.) are for employment-related illness or 

injury. Claims filed under EEOICPA (42 USC 7384 et seq.) are for compensable illnesses defined under that Act. All services, appliances, and supplies 

prescribed or recommended by a qualified physician, which the Secretary of Labor considers likely to give relief, reduce the degree or period of the disability 

or illness, or aid in lessening the amount of the monthly compensation, may be furnished. "Physician" includes all Doctors of Medicine (M.D.), podiatrists, 

dentists, clinical psychologists, optometrists, chiropractors, or osteopathic practitioners within the scope of their practice as defined by State law. However, 

the term "physician" includes chiropractors only to the extent that their reimbursable services are limited to treatment consisting of manual manipulation of the 

spine to correct a subluxation as demonstrated by x-ray to exist.

FEES: The Department of Labor's Office of Workers' Compensation Programs (OWCP) is responsible for payment of all reasonable charges stemming from 

covered medical services provided to claimants eligible under FECA and EEOICPA. OWCP uses a relative value scale fee schedule and other tests to 

determine reasonableness. Schedule limitations are applied through an automated billing system that is based on the identification of procedures as defined 

in the AMA's Current Procedural Terminology (CPT); correct CPT code and modifier(s) is required. Incorrect coding will result in inappropriate payment. For 

specific information about schedule limits, call the Dept. of Labor's Federal Employees' Compensation office or Energy Employees Occupational Illness 

Compensation office that services your area.

REPORTS: A medical report that indicates the dates of treatment, diagnosis(es), findings, and type of treatment offered is required for services provided by a 

physician (as defined above). For FECA claimants, the initial medical report should explain the relationship of the injury or illness to the employment. Test 

results and x-ray findings should accompany billings.

GENERAL INFORMATION-BLBA CLAIMANTS: The BLBA (30 USC 901 et seq.) provides medical services to eligible beneficiaries for diagnostic and 

therapeutic services for black lung disease as defined under the BLBA. For specific information about reimbursable services, call the Department of Labor's 

Black Lung office that services your facility or call the National Office in Washington, D.C. 

SIGNATURE OF PHYSICIAN OR SUPPLIER: Your signature in Item 31 indicates your agreement to accept the charge determination of OWCP on covered 

services as payment in full, and indicates your agreement not to seek reimbursement from the patient of any amounts not paid by OWCP for covered 

services as the result of the application of its fee schedule or related tests for reasonableness (appeals are allowed). Your signature in Item 31 also indicates 

that the services shown on this form were medically indicated and necessary for the health of the patient and were personally furnished by you or were 

furnished incident to your professional services by your employee under your immediate personal supervision, except as otherwise expressly permitted by 

FECA, Black Lung or EEOICPA regulations. For services to be considered as "incident" to a physician's professional service, 1) they must be rendered under 

the physician's immediate personal supervision by his/her employee, 2) they must be an integral, although incidental, part of a covered physician's service, 3) 

they must be of kinds commonly furnished in physician's offices, and 4) the services of non-physicians must be included on the bills. Finally, your signature 

indicates that you understand that any false claims, statements or documents, or concealment of a material act, may be prosecuted under applicable Federal 

or State laws.

NOTICE TO PATIENT ABOUT THE COLLECTION AND USE OF FECA, BLACK LUNG AND EEOICPA INFORMATION 

(PRIVACY ACT STATEMENT)

We are authorized by OWCP to ask you for information needed in the administration of the FECA, Black Lung and EEOICPA programs. Authority to collect 

information is in 5 USC 8101 et seq.; 30 USC 901 et seq.; 38 USC 613; E.O. 9397; and 42 USC 7384d, 20 CFR 30.11 and E.O. 13179. The information we 

obtain to complete claims under these programs is used to identify you and to determine your eligibility. It is also used to decide if the services and supplies 

you received are covered by these programs and to insure that proper payment is made. Your response regarding the medical service(s) received or the 

amount charged is required to receive payment for the claim. See 20 CFR §§ 10.801, 30.701, 725.406, 725.701, and 725.704. Failure to supply the claim 

number or CPT codes will delay payment or may result in rejection of the claim because of incomplete information. The information may also be given to 

other providers of services, carriers, intermediaries, medical review boards, health plans, and other organizations or Federal agencies, for the effective 

administration of Federal provisions that require other third party payers to pay primary to Federal programs, and as otherwise necessary to administer these 

programs. For example, it may be necessary to disclose information about the benefits you have used to a hospital or doctor. Additional disclosures are made 

through routine uses for information contained in systems of records. See Department of Labor systems DOL/GOVT-1, DOL/ESA-5, DOL/ESA-6, DOL/

ESA-29, DOL/ESA-30, DOL/ESA-43, DOL/ESA-44, DOL/ESA-49 and DOL/ESA-50 published in the Federal Register, Vol. 67, page 16816, Mon. April 8, 

2002, or as updated and republished. 

You should be aware that P.L. 100-503, the "Computer Matching and Privacy Protection Act of 1988," permits the government to verify information by way of 

computer matches.

FORM SUBMISSION 

DFELHWC-FECA: Send all forms for FECA to OWCP/DFELHWC-FECA, PO Box 8311, London, KY 40742-8311, (202) 513-6860 

DEEOIC: Send all forms for DEEOIC to Energy Employees Occupational Illness Compensation Programs, PO Box 8304, London, KY 40742-8304 

DCMWC: Send all forms for DCMWC to Federal Black Lung program, PO Box 8302, London, KY 40742-8302 

DFELHWC-LHWC: Send all forms for LHWC to OWCP/DFELHWC - LHWC, PO Box 8313, London, KY 8313

INSTRUCTIONS FOR COMPLETING THE FORM: A brief description of each data element and its applicability to requirements under FECA, BLBA and

EEOICPA are listed below. For further information contact OWCP.

Item 1. Leave blank. 

Item 1a. Enter the patient's claim number. 

Item 2. Enter the patient's last name, first name, middle initial. 

Item 3. Enter the patient's date of birth (MM/DD/YY) and check appropriate box for patient's sex. 

Item 4. For FECA: leave blank. For BLBA and EEOICPA: complete only if patient is deceased and this medical cost was paid by a survivor or estate. 

Enter the name of the party to whom medical payment is due. 

Item 5. Enter the patient's address (street address, city, state, ZIP code; telephone number is optional). 

Item 6. Leave blank. 

Item 7. For FECA: leave blank. For BLBA and EEOICPA: complete if Item 4 was completed. Enter the address of the party to be paid. 

Item 8. Leave blank. 

Item 9. Leave blank. 

Item 10. Leave blank. 

Item 11. For FECA: enter patient's claim number. OMISSION WILL RESULT IN DELAYED BILL PROCESSING. For BLBA and EEOICPA: leave blank. 

OMB No. 1240-0044 OWCP-1500 PAGE 2 (Rev. 06-15) 

Expires: 06/30/2024
Item 11a. Leave blank. 

Item 11b. Leave blank. 

Item 11c. Leave blank. 

Item 11d. Leave blank. 

Item 12. The signature of the patient or authorized representative authorizes release of the medical information necessary to process the claim, and 

requests payment. Signature is required; mark (X) must be co-signed by witness and relationship to patient indicated. 

Item 13. Signature indicates authorization for payment of benefits directly to the provider. Acceptance of this assignment is considered to be a 

contractual arrangement. The "authorizing person" may be the beneficiary (patient) eligible under the program billed, a person with a power of 

attorney, or a statement that the beneficiary's signature is on file with the billing provider. 

Item 14. Leave blank. 

Item 15. Leave blank. 

Item 16. Leave blank. 

Item 17. Leave blank. 

Item 18. Leave blank. 

Item 19. Leave blank. 

Item 20. Leave blank. 

Item 21. Enter the diagnosis(es) of the condition(s) being treated using current ICD codes. Enter codes in priority order (primary, secondary condition). 

Coding structure must follow the International Classification of Disease, 10th Edition, Clinical Modification or the latest revision published. A 

brief narrative may also be entered but not substituted for the ICD code. 

Item 22. Leave blank. 

Item 23. Leave blank. 

Item 24. Column A: enter month, day and year (MM/DD/YY) for each service/consultation provided. If the "from" and "to" dates represent a series of 

identical services, enter the number of services provided in Column G. 

Column B: enter the correct CMS/OWCP standard "place of service" (POS) code (see below). 

Column C: not required. 

Column D: enter the proper five-digit CPT (current edition) code and modifier(s), the HCPCS, or the OWCP generic procedure code. 

Column E: enter the diagnostic reference letter (A, B, C, etc. in Item 21) to relate the date of service and the procedure(s) performed to the 

appropriate ICD code, or enter the appropriate ICD code. 

Column F: enter the total charge(s) for each listed service(s). 

Column G: enter the number of services/units provided for period listed in Column A. Anesthesiologists enter time in total minutes, not units. 

Column H: Leave blank. 

Column I: Leave blank. 

Column J: Enter NPI. For FECA: required. OMISSION WILL RESULT IN DELAYED BILL PROCESSING. 

Item 25: Enter the Federal tax I.D. 

Item 26: Provider may enter a patient account number that will appear on the remittance voucher. 

Item 27: Leave blank. 

Item 28: Enter the total charge for the listed services in Column F. 

Item 29: If any payment has been made, enter that amount here. 

Item 30: Enter the balance now due. 

Item 31: For BLBA and EEOICPA: sign and date the form. For FECA: signature stamp or "signature on file" is acceptable. 

Item 32: Enter complete name of hospital, facility or physician's office were services were rendered. Item 32a. Enter NPI. Item 32b. Enter taxonomy 

number. 

Item 33: Enter (1) the name and address to which payment is to be made, and (2) your DOL provider number after "PIN #" if you are an individual 

provider, or after "GRP #" if you are a group provider. FAILURE TO ENTER THIS NUMBER WILL DELAY PAYMENT OR CAUSE A 

REJECTION OF THE BILL FOR INCOMPLETE/INACCURATE INFORMATION. 

Item 33a. Enter NPI. 

Item 33b. Enter taxonomy number. 

Place of Service (POS) Codes for Item 24B 

OMB No. 1240-0044 OWCP-1500 PAGE 3 (Rev. 06-15) 

Expires: 06/30/2024

34 Hospice 

41 Ambulance - Land 

42 Ambulance - Air or Water 

49 Independent Clinic 

50 Federally Qualified Health Center 

51 Inpatient Psychiatric Facility 

52 Psychiatric Facility Partial Hospitalization 

53 Community Mental Health Center (CMHC) 

54 Intermediate Care Facility/Mentally Retarded 

55 Residential Substance Abuse Treatment Facility 

56 Psychiatric Residential Treatment Center 

57 Non-Residential Substance Abuse Treatment Center 

60 Mass Immunization Center 

61 Comprehensive Inpatient Rehabilitation Facility 

62 Comprehensive Outpatient Rehabilitation Facility 

65 End Stage Renal Disease Treatment Facility 

71 State or Local Public Health Clinic 

72 Rural Health Clinic 

81 Independent Laboratory 

99 Other Place of Service 

2 Telehealth 

3 School 

4 Homeless Shelter 

5 Indian Health Service Free-Standing Facility 

6 Indian Health Service Provider-Based Facility 

7 Tribal 638 Free-Standing Facility 

8 Tribal 638 Provider-Based Facility 

9 Prison 

11 Office 

12 Patient Home 

13 Assisted Living 

14 Group Home 

15 Mobile Unit 

17 Walk in Retail Health Clinic 

18 Place of Employment/Worksite 

19 Off Campus Outpatient Hospital 

20 Urgent Care 

21 Inpatient Hospital 

22 Outpatient Hospital 

23 Emergency Room - Hospital 

24 Ambulatory Surgical Center 

25 Birthing Center 

26 Military Treatment Facility 

31 Skilled Nursing Facility 

32 Nursing Facility 

33 Custodial Care Facility 
OMB No. 1240-0044 OWCP-1500 PAGE 4 (Rev. 06-15) 

Expires: 06/30/2024

NOTICE 

 

If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in 

the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of 

documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the 

limitations of your disability. Please contact our office or your claims examiner to ask about this assistance.

Public Burden Statement 

 

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of 

information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1240-0044. We estimate that it will 

take an average of seven minutes to complete this collection of information, including time for reviewing instructions, abstracting information from the patient's 

records and entering the data onto the form. This time is based on familiarity with standardized coding structures and prior use of this common form. Send 

comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of 

Workers' Compensation Programs, Department of Labor, Room S3522, 200 Constitution Avenue NW, Washington, DC 20210; and to the Office of 

Management and Budget, Paperwork Reduction Project (1240-0044), Washington, DC 20503. DO NOT SEND THE COMPLETED FORM TO EITHER OF 

THESE OFFICES.