- Health Insurance Claim Form OWCP-1500, HCFA-1500:
Medical bills from physicians, chiropractors, therapists, radiologists, laboratories, podiatrists, nursing services and medical equipment and goods providers MUST be on this form; dentists, ambulance services and acupuncturists are encouraged to use the form.
- UB-82 or UB-92: All hospital bills must be on this form;
nursing homes are encouraged to use this form.
- SF-1012 (Travel Voucher): For reimbursement of mileage, parking fees and other travel related expenses that are a part of the claim.
- Pharmacies must use the Universal Claim Form.
- Veterans Administration facilities may submit claims using Form VA-10-9014.
An injured employee who has paid a provider may request reimbursement by submitting a completed OWCP-1500 signed by the provider. Hospital bills must be stamped "paid" or certified to show that payment has been received. A copy of the canceled check should be submitted to support reimbursement.
Reimbursement for prescriptions should include the prescription receipt indicating the name of the drug, the National Drug Code, quantity of drug, and the strength of the drug.
BILLS SHOULD BE SENT TO: DFEC CENTRAL MAILROOM, P.O. BOX 8300, LONDON, KY 40742, WITH THE CLAIM NUMBER WRITTEN ON THE TOP RIGHT HAND CORNER OF EVERY PAGE.