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Form OWCP-957 Part A
November 2023
Return this completed form to the appropriate program at the following address to prevent a delay in the processing of your bills.
Office of Workers’ Compensation Programs
Federal Employees’ Compensation Act
(FECA)
Division of Federal Employees’, Longshore,
and Harbor Workers’ Compensation
(DFELHWC)
PO Box 8300
London, KY 40742-8300
If you have any questions regarding the
completion of the form, please call
Toll Free: 1-844-493-1966.
Division of Energy Employees Occupational Illness
Compensation (DEEOIC)
Energy Employees Occupational Illness Compensation
Program
PO Box 8304
London, KY 40742-8304
Or submit electronically via Energy Document Portal
(EDP)
If you have any questions regarding the completion of
the form, please call
Toll Free: 1-866-272-2682.
FOR ENERGY EMPLOYEES ONLY
Note: Pre-authorization from the Medical Benefits Adjudication Unit is needed for travel exceeding 100 miles one way or 200
miles roundtrip. To contact the Medical Benefit Adjudication Unit call, toll free 1-866-272-2682.
PUBLIC BURDEN
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB
control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing
instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. The
obligation to respond to this collection is voluntary (5 U.S.C. 8101 et seq; 30 USC 901 et seq; 42 USC 7384 et seq,) to obtain or retain a benefit. Send comments
regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of
Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room S-3524, Washington, DC 20210,
and reference the OMB Control Number 1240-0037. Note: Please do not return the completed form to this Office.
PRIVACY ACT STATEMENT
The Privacy Act of 1974, as amended (5 USC 552a) authorizes OWCP to ask for information needed in the administration of the FECA, Black Lung and
EEOICPA programs. Authority to collect information is in the Federal Employees’ Compensation Act, 5 USC 8101 et seq.; the Black Lung Benefits Act, 30 USC
901 et seq.; and the Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384 et seq., and P.L. 103-196. The
information we obtain with this form is used to identify you and to determine your eligibility for reimbursement. It is also used to decide if the services and supplies
you received are covered by these programs and to ensure that proper payment is made. There are no penalties for failure to supply information; however, failure
to furnish information regarding the medical service(s) received or the amount charged will prevent payment of the claim. 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/OWCP-2, DOL/OWCP-11 published
in the Federal Register, Vol. 81, page 25766, or as updated and republished.