Form Owcp 957 – Fill Out and Use This PDF

In box 1, enter claimant's full name: last name, first name, middle initial (M.I.).

In box 2, enter claimant's claim/case file number.

In box 3, enter payee's full name (if person other than the claimant is to be reimbursed): last name, first name, middle initial.

In box 3, a payee other than the claimant must submit proof of special authorization. Not applicable to FECA Program.

In box 4, enter the Claimant's or Payee's phone number (No.) to reach with questions about this form.

In box 5, enter the street address of the person to be reimbursed including the: Street or Rural Route (RR), City, State, Zip Code

In box 5, for the FECA program to process your request, a FECA claimant must provide the home address where the claimant resides. A Post Office (PO) Box or attorney/ representative address is not an acceptable address.

In box 6, enter the Claimant's or Payee's email address to reach with questions about this form.

In box 7, complete a separate block for each medical facility, pharmacy, therapist, etc. visited as follows: Sample: Multiple trips to physical therapy office 31 miles from home.

In 7a, Date(s) of Travel, enter date(s) of travel. If you made multiple trips to the same location, you may enter multiple dates in this column.

In 7b, Reason for Travel, mark one box only: Hospital, Medical Appt., Therapy/Rehab, Pharmacy, Med. Supply or Other.

In 7c, From (Full name and street address), enter the full name and street address of the address where your trip started.

In 7d, To (Full name and street address), enter the full name and street address of the address where your trip ended.

In 7e, One-way /Round trip, mark one box only.

In 7f, Total # Miles, if it was a one-way trip, enter the number of miles. If it was a round trip, enter the total miles traveled for both legs of the trip.

In 8, enter the Claimant/Payee Signature and the Date.

"Payee Certification: I certify that the information provided is true and accurate to the best of my knowledge and belief."

Payee Certification: I am aware that any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud, to obtain reimbursement as provided by the OWCP, or who knowingly accepts reimbursement to which that person is not entitled is subject to civil or administrative remedies as well as criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment, or both. In addition, a state or federal criminal conviction for OWCP fraud will result in termination of all current and future OWCP benefits.

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.

Form OWCP-957 Part A December 2025, Page 3: Return this completed claim form to the appropriate program address.

This is a mileage only reimbursement form. If you need other travel expenses reimbursed, complete Form OWCP-957 Part B Medical Travel Refund Request - Expenses. For travel expenses reimbursement under the Black Lung Benefits Act (30 USC 901; 20 CFR 725.406 and 725.701) use the Form OWCP-957 Part B.