Fillable U.S. Department of Labor Medical Travel Refund Request

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U.S. Department of Labor Medical Travel Refund Request

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U.S. Department of Labor
Employment Standards Administration
Office of Workers' Compensation Programs
Medical Travel Refund Request
OMB No. 1215-0054
NOTE: This report is authorized by the Black Lung Benefits Act (30 USC 901, 20 CFR 725.406 and 725.701)
and the Energy Employees Occupational Illness Compensation Program Act (Public Law 106-398 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 services covered under the
Federal Black Lung Program and the Energy Employees Occupational Illness Compensation Program.
Expires: 06/30/2004
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:
DOL USE ONLY
FOR BLACK LUNG USE ONLY
f. Total expense/cost
TOS/Procedure Code
h. To be completed by Physician:
Taxi $
(Mark one box only)
$
Bus/Train
Care
c. Travel From:
d. Travel To:
Tolls/Pkg
Rendered
Treatment for Black Lung
Lodging
Hospital
Not Black Lung Related
Meals
Office/clinic
Determine, Test for Black Lung
Other
Lab
Diagnosis
(Specify)
Home
(Signature of Physician)
g. Private Auto Only
Miles traveled
(Date Care Rendered)
Total $
FOR BLACK LUNG USE ONLY
DOL USE ONLY
f. Total expense/cost
h. To be completed by Physician:
TOS/Procedure Code
Taxi $
$
(Mark one box only)
Bus/Train
Care
c. Travel From:
d. Travel To:
Tolls/Pkg
Rendered
Treatment for Black Lung
Hospital
Lodging
Not Black Lung Related
Office/clinic
Meals
Determine, Test for Black Lung
Lab
Other
Diagnosis
Home
(Specify)
e. Medical facility name and address
(Signature of Physician)
g. Private Auto Only
Miles traveled
(Date Care Rendered)
Total $
DOL USE ONLY
FOR BLACK LUNG USE ONLY
f. Total expense/cost
h. To be completed by Physician:
(Mark one box only)
TOS/Procedure Code
Taxi $
$
Bus/Train
Care
d. Travel To:c. Travel From:
Tolls/Pkg
Rendered
Treatment for Black Lung
Hospital
Hospital
Lodging
Not Black Lung Related
Office/clinic
Office/clinic Meals
Determine, Test for Black Lung
Lab
Lab
Other
Diagnosis
Home
(Specify)
Home
g. Private Auto Only (Signature of Physician)
Miles traveled
Total $
(Date Care Rendered)
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 also fully aware that any person who willfully makes any false or misleading statement
or representation for the purpose of obtaining any benefit or payment under this title shall be guilty of a misdemeanor and on
conviction thereof shall be punished by a fine of not more than $1,000, or by imprisonment for not more than one year or both.
Claimant's/Payee's Signature:
Date:
Form OWCP-957
Rev. Aug 2001
8.
2. Physician's signature or facsimile is REQUIRED by BLACK LUNG for verification of each service date and type.
e.
2. Social Security Number:
Hospital
Office/clinic
Lab
Home
Hospital
Office/clinic
Lab
Home
e. Medical facility name and address
5a. Date of Travel:
Round Trip
One-way
b.
Medical facility name and address
6a. Date of Travel:
Round Trip
One-way
b.
7a. Date of Travel:
Round Trip
One-way
b.
Reset
Print
Instructions (Form OWCP-957)
1. Enter claimant's full name: last name, first name, middle initial.
2. Enter claimant's Social Security Number.
Enter payee's full name (if person other than the minor or claimant is to be reimbursed): last name, first name, middle
initial. A payee other than the claimant must have special authorization.
Please explain the following:
a. Relationship to the claimant
b. The reason you are requesting reimbursement
4. Enter the address of the person to be reimbursed. The address is to include:
Street/RFD, City, State, Zip Code
5, 6, and 7. Complete a separate block for each medical facility visited on the same day. For travel on different
days, complete one block for each date.
a. Enter date of travel.
b. Mark one box only.
c. Mark one box only.
d. Mark one box only.
e. Enter the name and address of the medical facility.
f. Mark each box for which you are claiming reimbursement and list the amount of money spent for
each item.
g. Enter the total number of miles traveled by private automobile.
h. The physician or designee is to complete this item.
8. The person claiming reimbursement must sign here.
Attach all original receipts for expenses listed In 5f, 6f, and 7f. The claimant's full name and Social Security Number
should appear on each receipt.
FOR BLACK LUNG USE ONLY
Note: Only travel expenses for the miner are reimbursable
-
-
Special approval from the district office is needed for lodging or for travel exceeding 75 miles
one way or 150 miles round trip.
-
To obtain your district office telephone number, 1-800-638-7072.
-
Reimbursement for meals will be made only when authorized travel exceeds 24 hours or under special
circumstances.
Travel to pick up medicine, equipment or supplies in not reimbursable.
-
FOR ENERGY EMPLOYEES ONLY
Special approval from the district office is needed for travel exceeding 75 miles one way or 150 miles round trip. To
obtain your district office telephone number, call toll free 1-866-272-2682.
Public Burden Statement
We estimate that it will take an average of 10 minutes to complete this collection of information, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, send them to the U.S. Department of Labor, Office of Workers' Compensation, Room C3524, 200 Constitution
Avenue, N.W., Washington, D.C. 20210.
DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control
number.
Note:
3.
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U.S. Department of Labor Medical Travel Refund Request

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Completed 4 May 2021

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