OWCP-1500 Health Insurance Claim Form | The Center At Western Queens

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This form is used for claims under FECA, Black Lung Benefits Act, and EEOICPA. Complete all applicable fields. Fields marked "Leave Blank" are not required for your program. Submit your completed form to OWCP at the address listed in the instructions. OMB No. 1240-0044 · Expires 07/31/2027

Health Insurance Claim Form

Approved by National Uniform Claim Committee (NUCC)

FORM OWCP-1500 (03-25) · OMB No. 1240-0044 · Expires 07/31/2027

1a–4 Patient & Insured Identification

1a Insured's I.D. Number / Claim Number *

Item 4: Leave blank for FECA. Complete for BLBA/EEOICPA only if patient is deceased.

2 Patient's Name (Last, First, Middle Initial) *

4 Insured's Name (Last, First, MI)

3 Patient's Birth Date *

3 Sex *

M F

6 Patient Relationship to Insured

Self Spouse Child Other

5 Patient's Address & Contact

5 Street Address *

City *

State

ZIP Code

Telephone (Include Area Code)

8–11 Insurance & Policy Information

Items 8, 9, 10: Leave blank per OWCP instructions.

11 Insured's Policy Group / FECA Number *

11a Insured's Date of Birth

11a Insured's Sex

M F

11c Insurance Plan Name or Program Name

11d Is there another health benefit plan?

Yes No

12–13 Authorizing Signatures

Item 12: 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.

Patient / Authorized Person Signature *

Sign here

Date

Item 13: I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

Insured / Authorized Person Signature *

Sign here

14–20 Dates & Additional Information

Items 14, 15, 16, 17, 18, 19, 20: Leave blank per OWCP instructions.

23 Prior Authorization Number

22 Resubmission Code

22 Original Reference No.

21 Diagnosis or Nature of Illness / Injury (ICD Codes)

21 ICD Indicator

ICD-10 ICD-9

24 Date(s) of Service / Procedures

A. Date From	A. Date To	B. POS	C. EMG	D. CPT/HCPCS	D. Modifier	E. Dx Ptr	F. $ Charges	G. Units	J. NPI

25–30 Federal Tax ID, Account & Charges

25 Federal Tax I.D. Number *

25 SSN or EIN?

SSN EIN

26 Patient's Account No.

27 Accept Assignment?

Leave blank per OWCP instructions.

28 Total Charge *

29 Amount Paid

31–33 Physician / Supplier Information

Item 31: I certify that the statements on the reverse apply to this bill and are made a part thereof.

Physician / Supplier Signature *

Sign here

Date

Degrees / Credentials

32 Service Facility Name & Address

32a Facility NPI

32b Taxonomy

33 Billing Provider Name, Address & Phone *

33a Billing Provider NPI *

33b Billing Taxonomy *

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Claim Form Submitted

Your OWCP-1500 form has been sent to The Center at Western Queens and a copy has been emailed to you. A signed PDF has been downloaded to your device.

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