Form OWCP-1168 Provider Enrollment Form

Provider Enrollment Form

U.S. Department of Labor

Employment Standards Administration
Office of Workers' Compensation Programs
OMB Number 1215-0137
Expires:

Please refer to instructions for completing this form.
Provider Number

Effective Date

FOR DOL USE ONLY
1. Are you applying for a new enrollment or updating your record?

Update

New enrollment

1a. Program

If update, enter Provider Number or Employer Identification Number (EIN):

Black Lung

FECA
Energy

2. What is the earliest date that you treated a participant in any OWCP program?
Practice Information
3. Practice Name

4. Practice's Physical Address

5. City

6. State

8. Telephone

7.

9. FAX

10. Type of Practice a.

b.

Individual

Zip (9 digits)

9a. Email Address
Facility (Provider Types: 01, 02, 03, 05, 46, 89, 90, 92, 93, 94)

c.
Group (Please see reverse for completion of group enrollment)
Provider Type (Individual or Facility) (Please see attached listing)

11b. Provider Type Description (see attachment)

11a. Provider Type Code

11c. If you select "Other Provider" (96) or Non-Medical Vendor (53), please explain:
12. Tax ID: (EIN or SSN)
13. Required for hospitals only
13b. NPI:

13a. Medicare Number

1.

13c. Taxonomy Code(s):

1.

2.

2.

3.

3.

License and/or Certification required for all Applicants (Individual for M.D. and D.O. only)
14a. Name

14b. License No./ State

14e. Certification
Expiration Date

14c. Current License
Expiration Date

14d.
Specialty
Code(s)

16c. State

16d. Zip (9 digits)

15. United Mine Workers' of America (UMWA) Number, if applicable.
Billing Address-indicate "same" if identical to Practice Address.
16a. Address
16b. City
17.

I have completed a ACH Vendor Payment/Electronic Funds Transfer (EFT) form.

18.

I am interested in billing electronically (check one):

P2P Link

EDI

Web Submission

NOTICE: Anyone who misrepresents or falsifies essential information to receive payment from Federal funds may upon
conviction be subject to fine and imprisonment under applicable Federal laws.
Signature (Provider or Representative and Title)
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Date
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Form OWCP-1168
Revised June 2009

Group Provider Enrollment - #10c
For group practice enrollment, please enter the following information for each professional who will provide services under the
group EIN. Select from the list on page 4 the Provider Type code that most closely describes the service(s) that the professional provides.
Attach separate sheet for additional entries if necessary.
Name

Provider
Type
Code

SSN/EIN

License No./
State

Current License No.
Expiration Date

Specialty
Certification
Code(s) Expiration Date

Please return this completed form to the appropriate program at the following address to prevent a delay in the processing of your bills.
For Federal Employees'
Compensation Act (FECA)
Program:

For Black Lung Program:

For Energy Program:

OWCP/FECA
P.O. Box 8300

DCMWC/Black Lung
P.O. Box 8302

London, KY
40742-8300

London, KY
40742-8302

DEEOIC
P.O. Box 8304
London, KY
40742-8304

If you have any questions
regarding the completion
of the form, please call
Toll Free: 1-850-558-1818

If you have any questions
regarding the completion
of the form, please call
Toll Free: 1-800-638-7072

If you have any questions
regarding the completion
of the form, please call
Toll Free: 1-866-272-2682

Privacy Act Statement
Collection of this information by OWCP is necessary for its administration of the Federal Employees' Compensation Act, the Black Lung
Benefits Act and the Energy Employees Occupational Illness Compensation Program Act and is authorized under 20 CFR 10.801, 20 CFR
30.701, and 20 CFR 725.704 and 725.705. The information provided will be used to ensure accurate payment of medical and vocational
rehabilitation provider bills and is protected by the Privacy Act of 1974, as amended (5 USC 552a) in accordance with the following systems
of records: DOL/GOVT-1, DOL/ESA-6 and DOL/ESA-49, published in the Federal Register, Vol. 67, page 16816, April 8, 2002, or as
updated and republished. Completion and submission of this form is voluntary; however, failure to provide the information (including SSN
or EIN) will result in substantially delayed payment of bills. This information will be furnished to OWCP and its data processing contractors,
and may also be disclosed to other federal and state agencies in connection with the administration of other programs, to the Department of
Justice for litigation purposes, and to medical and other provider review boards. Additional disclosures may be made through the routine
uses for information contained in the referenced systems of records.

Public Burden Statement
Under the Paperwork Reduction Act, persons are not required to respond to a collection of information unless such collection displays a
valid OMB control number. Completion and submission of this form is voluntary; however, failure to provide the information will result in
substantially delayed payment of bills. We estimate that it will take an average of 8 minutes to complete this information collection,
including time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the information. If you have any comments regarding these estimates or any other aspect of this collection, including
suggestions for reducing this burden, send them to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room
S-3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THE ABOVE ADDRESS
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Form OWCP-1168
Revised June 2009

Instructions
A brief description of each data element is listed below. Be sure to sign and date the form when
you submit it. For further information contact Affiliated Computer Science or Office of Workers' Compensation
Programs at the telephone numbers indicated on the form.
Block 1

Indicate whether this form is being used for a new enrollment, or to update an
existing enrollment record. If the form is being submitted to update your record,
enter your Provider Number or Employer Identification Number.

Block 1a

Check all programs in which you want to enroll as a provider.

Block 2

Indicate earliest date you treated any OWCP beneficiary.

Block 3

Type or print your practice name.

Block 4

Type or print your practice street address.

Block 5

Type or print your practice city.

Block 6

Type or print your practice state.

Block 7

Type or print your practice zip code (all nine digits).

Block 8

Type or print your practice telephone number.

Block 9

Type or print your practice FAX number (if applicable).

Block 9a

Type or print your practice email address (if applicable).

Block 10

Check your practice type---"a" for individual practice, "b" for a facility if you are
one of the provider types listed (refer to the list of provider type codes below), or
"c" for a group practice. Black Lung only: providers should disregard group
practice information. If you checked "c" (group practice), fill out the appropriate
parts of Block 10c on page two of the form for each professional that will be
providing services under the group Provider Number (name, Social Security
number, provider type code from list below, license number and State, expiration
date of current license, specialty code or codes from the list below, and the date
any certification expires). Continue on a separate sheet if necessary.

Block 11a

If you checked "a" or "b" (individual practice or facility) in Block 10, type or print
your "Provider Type" code from the list below.

Block 11b

If you checked "a" or "b" (individual practice or facility) in Block 10, type or print
the "Provider Type" that corresponds with the code you entered in Block 11a.

Block 11c

If you checked "a" or "b" (individual practice or facility) in Block 10 and selected
"Other Provider" (code 96) or "Non-Medical Vendor (code 53), please explain
why you are enrolling.

Block 12

If you checked "a" or "b" (individual practice or facility) in Block 10, type or print
your Social Security number and/or your EIN, as appropriate.

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Form OWCP-1168
Revised June 2009

Block 13a

For hospitals only, type or print your Medicare number.

Block 13b

For hospitals only, type or print your National Provider Identifier (NPI)
number(s). Use as many lines as needed.

Block 13c

For hospitals only, type or print all applicable taxonomy codes.

Block 14a

If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O,
type or print your name.

Block 14b

If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O,
type or print your license number and State. Attach a copy of current M.D. or
D.O. license.

Block 14c

If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O,
type or print the expiration date of your current license. This license must be
kept current to continue receiving payment.

Block 14d

If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O,
type or print your specialty code or codes from the list below.

Block 14e

If you checked "a" (individual practice) in Block 10 and you are an M.D. or a D.O,
type or print the expiration date of any certification you currently hold.

Block 15

Type or print your UMWA Health & Retirement Funds Member Number, if any.

Block 16a

Type or print the address where you want your Remittance Advices and paper
checks to be sent. If this address is identical to your billing address above in
Blocks 4 through 7, indicate "same" and skip Blocks 16b, 16c and 16d.

Block 16b

Type or print your billing city if this is different from Block 5.

Block 16c

Type or print your billing State if this is different from Block 6.

Block 16d

Type or print your billing zip code (all nine digits) if this is different from Block 7.

Block 17

Indicate whether you have completed an ACH Vendor Payment or Electronic
Funds Transfer (EFT) form.

Block 18

Indicate whether you are interested in billing electronically by checking the first
box. If you check the first box, also indicate which of the three billing methods
you will use.

*******

Provider/Hospital Type Codes (Blocks 10c, 11a, and 11b)
01
02
03
05
19
20
25

General Hospital
Special Hospital/Outpatient Rehabilitation Facility
Psychiatric Hospital
Community Mental Health Center
End Stage Renal Hospital
Pharmacy
Physician (MD)

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Form OWCP-1168
Revised June 2009

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41
42
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44
45
46
50
51
52
53
54
55
56
57
58
59
60
61
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65
66
68
69
70
71
72
73
74
75
76
77
78
79
80
88
89
90
91
92
93
94

Physician (DO)
Podiatrist
Chiropractor
Physician Assistant
Advanced Registered Nurse Practitioner (ARNP)
Certified Registered Nurse Anesthetist (CRNA)
Psychologist
Licensed Midwife
Dentist
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Nursing Attendant
Massage Therapist
Ambulance
Contract Nurse
Air/Water Ambulance Company
Taxi
Public Transportation
Private Transportation
Hospice
Independent Laboratory
Portable X-Ray Company
Alternative Medicine
Non-Medical Vendor
Prosthetics/Orthotics
Vocational Rehabilitation (Training, Tuition and Schools)
Vocational Rehabilitation Counselor
Rehabilitation Maintenance
Assisted Re-employment
Relocation Expenses
Audiologist/Speech Pathologist
Second Opinion Contractor
Optometrist
Optician
Home Health Agency
Rural Health Clinic
Federally Qualified Health Center
Birthing Center
Health Maintenance Organization or Preferred Health Plan
Physical Therapist
Occupational Therapist
Pulmonary Rehabilitation
Outpatient Renal Dialysis Facility
Medical Supplies/Durable Medical Equipment (DME)
Case Management Agency
Social Worker
Blood Bank
Alternative Payee
Pay-to-Intermediary
Ambulatory Surgery Center
Federal Facility (VA Hospital)
Skilled Nursing Facility (SNF)-Medicare Certified
Skilled Nursing Facility (SNF)-Non-Medicare Certified
Intermediate Care Facility (ICF)
Rural Hospital Swing Bed
Boarding House

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Form OWCP-1168
Revised June 2009

95
96
97
98

Insurance Company (Third Party Carriers)
Other Provider
Billing Agent
Lien holder

*******
Provider Specialty Codes (Blocks 10c and 14d)
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
20
21
22
24
25
26
27
28
29
30
31
32
33
34
40
41
42
44
45
46
47
48
50

Adolescent Medicine
Allergy
Anesthesiology
Cardiovascular Disease
Dermatology
Diabetes
Emergency Medicine
Endocrine Medicine
Family Practice
Gastroenterology
General Practice
Preventative Medicine
Geriatrics
Gynecology
Hematology
Immunology
Infectious Diseases
Internal Medicine
Neoplastic Diseases
Nephrology
Neurology
Neuropathology
Nutrition
Obstetrics
Obstetrics and Gynecology
Occupational Medicine
Oncology
Ophthalmology
Otolaryngology
Pathology
Pathology, Clinical
Pathology, Forensic
Pharmacology
Physical medicine and rehab
Psychiatry
Psychoanalysis
Public Health
Pulmonary diseases
Radiology
Diagnostic radiology
Therapeutic radiology

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60
61
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64
65
70
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74
88
90
91
92
93
99

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Rheumatology
Abdominal surgery
Cardiovascular surgery
Colon and rectal surgery
General surgery
Hand surgery
Neurological surgery
Orthopedic surgery
Plastic surgery
Thoracic surgery
Traumatic surgery
Urological surgery
Other physician specialty
Maternal fetal medicine
Adult, dentures only
General dentist
Oral surgeon, dentist
Other dentist
Orthodontist
Occupational therapist
Physical therapist
Speech therapist
Respiratory therapist
Other

Form OWCP-1168
Revised June 2009