Office of Workers' Compensation Programs Forms and Office Locations – Government Agency in U.S.

1 - 20 of 31 forms

Form Title	Topics
Agreement and Undertaking
Application for Approval of a Representative's Fee in a Black Lung Claim Proceeding Conducted by The U.S. Department of Labor
Application or Renewal of Self-Insurance Authority
Authorization For Release Of Medical Information (Black Lung Benefits)
Certificate of Medical Necessity
Certification by School Official
Claim For Medical Reimbursement
Employment History
Financial Summary for Self-Insured Operators
Health Insurance Claim Form
Instructions For Completion of Form CM-921
Medical History and Examination for Coal Mine Workers' Pneumoconiosis
Medical Travel Refund Request – Expenses
Miner's Claim For Benefits Under The Black Lung Benefits Act
Notice of Termination, Suspension, Reduction or Increase in Benefit Payments
Operator Response to Notice of Claim
Operator Response to Schedule for Submission of Additional Evidence
Overpayment Recovery Questionnaire
Physician's/Medical Officer's Statement
Report of Arterial Blood Gas Study