Get Ca 915 Form Fillable

The CA 915 Form Fillable is used to request reimbursement for medical expenses incurred due to work-related injuries. This guide provides clear and concise instructions for filling out the form online, ensuring that users can successfully submit their claims.

Follow the steps to complete the CA 915 Form Fillable online

1. Click the ‘Get Form’ button to obtain the CA 915 Form and open it in the online editor.
2. Enter the claimant’s name in the format of Last, First, Middle Initial in the designated field.
3. Input the claimant’s Social Security Number in the appropriate space.
4. If applicable, provide the claimant’s OWCP case file number, noting that this field is optional.
5. Fill in the claimant’s contact number for any necessary follow-up.
6. Provide the claimant’s full address, including number and street, city, state, and ZIP code.
7. List medical charges related to services covered under the Federal Employees’ Compensation Program. Use a separate line for each charge.
8. Specify the name of the medical provider (doctor, hospital, pharmacy, etc.) involved.
9. Describe the service provided, mentioning whether it was a prescription drug, office visit, or durable medical equipment.
10. Enter the date of service or purchase, formatted as Month, Day, Year.
11. Record the total amount paid by the claimant for the services listed.
12. Ensure to sign and date the form to certify that the information provided is accurate.
13. Finally, save the changes, download the completed form, print it, and share it as needed, ensuring to attach itemized bills and receipts.

Complete your CA 915 Form online today to initiate your reimbursement process.