Block 17 Enter status code. 

Block 18 Enter condition codes. 

Block 19 Enter condition codes. 

Block 20 Enter condition codes. 

Block 21 Enter condition codes. 

Block 22 Enter condition codes. 

Block 23 Enter condition codes. 

Block 24 Enter condition codes. 

Block 25 Enter condition codes. 

Block 26 Enter condition codes. 

Block 27 Enter condition codes. 

Block 28 Enter condition codes. 

Block 29 Not required. 

Block 30 Blank field.

Block 31 Enter occurrence code and occurrence date. 

Block 32 Enter occurrence code and occurrence date. 

Block 33 Enter occurrence code and occurrence date. 

Block 34 Enter occurrence code and occurrence date. 

Block 35 Enter occurrence span code and occurrence span from date. 

Block 36 Enter occurrence span code and occurrence span from date.

Block 37 Blank field. 

Block 38 Not required. 

Block 39 Enter value code 01-99 and A 1-29, and value codes amount. 

Block 40 Enter value code 01-99 and A 1-29, and value codes amount. 

Block 41 Enter value code 01-99 and A 1-29, and value codes amount. 

Block 42 Type or print Revenue Center Code(s). 

Block 43 Block 43 Type or print Revenue Center Code description(s). (If billing an unlisted J-Code with RCC 0636, a valid NDC Code must be specified in this 

block and the drug quantity listed in Block 46.) 

Block 44 Type or print applicable private/semi-private room rate, and the CPT or HCPCS codes and modifiers based on bill type (inpatient or outpatient). Block 45 

Enter service date for outpatient services not required for inpatient for each RCC. 

Block 46 Type or print units of service for inpatient. For outpatient, enter units of service for each RCC. 

Block 47 Type or print total charges by RCC and procedure code. 

Block 48 Not required. 

Block 49 Blank field. 

Block 50 Type or print program payer: U.S. DOL-OWCP-FECA, -BLBA or -EEOICPA, as appropriate, and Medicare number (51 B) for inpatient services. Block 51 

Medicare number 51 B. 

Block 52 Not required. 

Block 53 Not required. 

Block 54 Type or print the amount of any prior payments made. 

Block 55 Not required. 

Block 56 Required. Enter Billing provider NPI. 

Block 57 Type or print other provider ID. OWCP provider number. 

Block 58 Type or print insured's last name, first name. 

Block 59 Not required. 

Block 60 For EEOICPA and BLBA: type or print patient's SSN. For FECA: type or print patient's claim/case number. 

Block 61 Not required. 

Block 62 Not required. 

Block 63 Not required. 

Block 64 Not required. 

Block 65 Not required. 

Block 66 Type or print ICD diagnosis version. 

Block 67a Type or print complete ICD-9-CM/ICD-10 diagnosis code for principal diagnosis. Enter the 4th and 5th digits if applicable. Each diagnosis must 

be valid for the date of service. 

Block 67b Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67c Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67d Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67e Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67f Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67g Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67h Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67i Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67j Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67k Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 671 Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67mType or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67n Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 670 Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67p Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 67q Type or print complete ICD-9-CM/ICD-10 diagnosis code for other diagnosis (if applicable). 

Block 68 Blank field. 

Block 69 Type or print complete ICD-9-CM/ICD-10 diagnosis code for admission diagnosis. Enter the 4th and 5th digit if applicable. Ea ch diagnosis must be 

valid for the date of service. 

Block 70 Type or print patient's reason for visit code. 

Block 71 Not required. 

Block 72 Not required. 

Block 73 Blank field. 

Block 74 Type or print principal procedure using ICD-9-CM codes and date of occurrence (MM/DD/YY) during hospitalization. Inpatient claims and all surgical 

procedures require ICD -9-CM procedure codes. Outpatient claims require CPT/HCPCS codes. 

Block 74a Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require 

ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes. OWCP-04 PAGE 3 (Rev. 06_12) 
Block 74b Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require 

ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes. 

Block 74c Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require 

ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes. 

Block 74d Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require 

ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes. 

Block 74e Type or print any other procedure using ICD-9-CM codes and dates of occurrence (MM/DD/YY). Inpatient claims and all surgical procedures require 

ICD-9-CM procedure codes. Outpatient claims require CPT/HCPCS codes. 

Block 75 Blank field. 

Block 76 Enter Attending provider NPI. When attending NPI is entered, attending taxonomy is required in Block 81CCb and,vice versa. 

Block 77 Not required. 

Block 78 Not required. 

Block 79 Not required. 

Block 80 Not requ�. 

Block8.:\ 

81CCa: Required. Enter Taxonomy code for the billing provider. OMISSION WILL RESULT IN DELAYED BILL PROCESSING.

81CCb: Required. Enter Taxonomy code for the attending provider. When attending taxonomy is entered attending NPI is required in Block 76 and vice versa. 

Public Burden Statement 

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

unless it displays a valid 0MB control number. The valid 0MB control number for this information collection is 1240-0019. 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 as pect of this collection of infomation, including suggestions for reducing this burden, to the Office of Workes' 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 (1240-0019), Washington, DC 20503. DO NOT SEND THE COMPLETED FORM TO EITHER OF THESE OFFICES.

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. 

OWCP-04 PAGE 4 (Rev. 06-12)