Medical / Health Insurance Forms
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Billing Change Form - The Federal Long Term Care Insurance Program |
pdf |
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Premium Conversion Waiver/Election Form - Federal Employees Health Benefits Program |
pdf |
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DS-1622 |
Medical History and Examination for Foreign Service (For Children 11 Years and Under) |
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DS-1843 |
Medical History and Examination for Foreign Service (For Individuals Age 12 and Older) |
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DS-3057 |
Medical Clearance Update |
pdf |
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DS-6561 |
Pre-Assignment for Overseas Duty (Non-Foreign Service Personnel) |
pdf |
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OWCP-5-B |
Work Capacity Evaluation for Cardiovascular/Pulmonary Conditions |
pdf |
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OWCP-5-C |
Work Capacity Evaluation for Musculoskeletal Conditions |
pdf |
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OWCP-16 |
Rehabilitation Plan and Award |
pdf |
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OWCP-17 |
Rehabilitation Maintenance Certificate |
pdf |
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OWCP-20 |
Overpayment Recovery Questionnaire |
pdf |
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OWCP-44 |
Rehabilitation Action Report |
pdf |
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OWCP-915 |
Claim for Medical Reimbursement |
pdf |
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OWCP-957 |
Medical Travel Refund Request |
pdf |
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OWCP-1500 |
Health Insurance Claim Form |
pdf |
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SF-2809 |
Health Benefits Election Form - Federal Employees Health Benefits Program |
pdf |
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UB-4 |
Medicare Claims Processing |
pdf |
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WH-380 |
Certification of Health Care Provider (Family and Medical Leave Act) |
pdf |
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WH-380-E |
Certification of Health Care Provider for Employee's Serious Health Condition (Family and Medical Leave Act) |
pdf |
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WH-380-F |
Certification of Health Care Provider for Family Member's Serious Health Condition (Family and Medical Leave Act) |
pdf |
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