Form owcp 957 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the claimant's full name in the designated field, including last name, first name, and middle initial.
3. Input the claim/case number accurately to ensure proper processing of your request.
4. If a payee is different from the claimant, provide their full name and relationship to the claimant. This requires special authorization.
5. Fill in the payee's address, ensuring it includes street/RFD, city, state, and zip code for accurate correspondence.
6. For each medical facility visited on the same day, complete a separate block. Enter the date of travel and select whether it was one-way or round trip.
7. Specify the travel details by marking appropriate boxes for 'Travel From' and 'Travel To', along with the medical facility's name and address.
8. List all expenses incurred for each trip segment in the corresponding fields and total them accurately.
9. Ensure that a physician completes any required sections for Black Lung claims before signing off on your submission.
10. Finally, sign and date the certification section to confirm that all information provided is true and correct.

Start using our platform today to streamline your form completion process for free!