Provider Enrollment Form

ICR 201003-1240-021

OMB: 1240-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2009-09-24
IC Document Collections
IC ID
Document
Title
Status
38462 Modified
ICR Details
1240-0021 201003-1240-021
Historical Active 200610-1215-005
DOL/OWCP
Provider Enrollment Form
Extension without change of a currently approved collection   No
Regular
Approved without change 03/12/2010
Retrieve Notice of Action (NOA) 03/12/2010
  Inventory as of this Action Requested Previously Approved
11/30/2012 36 Months From Approved
70,185 0 48,242
9,335 0 6,417
32,987 0 17,736

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

Not associated with rulemaking

  74 FR 29721 06/23/2009
74 FR 51173 10/05/2009
No

1
IC Title Form No. Form Name
Provider Enrollment Form OWCP-1168 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 70,185 48,242 0 0 21,943 0
Annual Time Burden (Hours) 9,335 6,417 0 0 2,918 0
Annual Cost Burden (Dollars) 32,987 17,736 0 0 15,251 0
No
No
The bulk of respondents already enrolled in the three programs were required to re-enroll with current information due to the necessity to obtain new information required by other Federal agencies, i.e, the National Provider Identification (NPI) number and taxonomy codes. There has been an increase in the number of respondents seeking to provide medical or vocational services to beneficiaries. Therefore, there is an adjustment of +2,918 in burden hours and +$15,251 in operational and maintenance costs.

$1,846,391
No
No
Uncollected
Uncollected
No
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.
10/06/2009


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