Provider Enrollment Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0021 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-1168 Provider Enrollment Form Form
OWCP-1168 Provider Enrollment Form OWCP-1168_revised draft (8-28-09).pdf //owcp.dol.acs-inc.com/portal/formsAndLinks.do Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Provider Enrollment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 725.704 20 CFR 725.705 20 CFR 30.701 20 CFR 10.801

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	OWCP-1168	Provider Enrollment Form	OWCP-1168_revised draft (8-28-09).pdf	http>//owcp.dol.acs-inc.com/portal/formsAndLinks.do	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: DOL/GOVT-1(for FECA); DOL/ESA-6(for BLBA); AND DOL/ESA-49 (for EEOICPA)	FR Citation: 67 FR 16826

Number of Respondents: 70,185	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	70,185	21,943	48,242
Annual IC Time Burden (Hours)	9,335	2,918	6,417
Annual IC Cost Burden (Dollars)	32,987	15,251	17,736

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.