Provider Enrollment Form

ICR 200610-1215-005

OMB: 1215-0137

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2006-10-31
Supplementary Document
2006-10-31
IC Document Collections
IC ID
Document
Title
Status
38462 Modified
ICR Details
1215-0137 200610-1215-005
Historical Active 200506-1215-005
DOL/ESA
Provider Enrollment Form
Extension without change of a currently approved collection   No
Regular
Approved without change 01/09/2007
Retrieve Notice of Action (NOA) 11/08/2006
  Inventory as of this Action Requested Previously Approved
01/31/2010 36 Months From Approved 03/31/2007
48,242 0 13,600
6,417 0 1,809
17,736 0 5,000

Form OWCP-1168 requests profile information on providers that enroll in one (or more) of OWCP's benefit programs so its billing contractor can pay them for services rendered to beneficiaries using its automated bill processing system.

US Code: 5 USC 8101 Name of Law: The Federal Employees' Compensation Act (FECA)
   US Code: 30 USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
   US Code: 42 USC 7384 Name of Law: The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 33 USC 901 Name of Law: The Longshore and Harbor Workers' Compensation Act (LHWCA)
  
None

Not associated with rulemaking

  71 FR 40737 07/18/2006
71 FR 65545 11/08/2006
No

1
IC Title Form No. Form Name
Provider Enrollment Form OWCP-1168, OWCP-1168 Provider Enrollment Form ,   Provider Enrollment Form

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 48,242 13,600 0 0 34,642 0
Annual Time Burden (Hours) 6,417 1,809 0 0 4,608 0
Annual Cost Burden (Dollars) 17,736 5,000 0 0 12,736 0
No
No
Since the bulk of providers enrolled in the four programs were required to re-enroll with current information, Form OMB 83-I shows an adjusment of +4608 burden hours and +$15,262 operational and maintenance costs.

$1,276,477
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Sheldon Turley 202-693-5337 Turley.Sheldon@dol.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
11/08/2006


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