Provider Enrollment Form

ICR 201207-1240-004

OMB: 1240-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
Supporting Statement A
2012-09-25
IC Document Collections
IC ID
Document
Title
Status
38462 Modified
ICR Details
1240-0021 201207-1240-004
Historical Active 201003-1240-021
DOL/OWCP
Provider Enrollment Form
Revision of a currently approved collection   No
Regular
Approved without change 01/08/2013
Retrieve Notice of Action (NOA) 11/07/2012
  Inventory as of this Action Requested Previously Approved
01/31/2016 36 Months From Approved 01/31/2013
53,934 0 70,185
7,174 0 9,335
25,888 0 32,987

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

  77 FR 43126 07/23/2012
77 FR 66869 11/07/2012
No

1
IC Title Form No. Form Name
Provider Enrollment Form OWCP-1168, OWCP-1168 Web version screen shots Provider Enrollment Form ,   Provider Enrollment For, Screen Shots

  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 53,934 70,185 0 0 -16,251 0
Annual Time Burden (Hours) 7,174 9,335 0 0 -2,161 0
Annual Cost Burden (Dollars) 25,888 32,987 0 0 -7,099 0
No
No
There has been a decrease in the number of respondents seeking to provide medical or vocational services to beneficiaries. There is an adjustment of -2,161 in burden hours and -$7,099 in operational and maintenance costs. While not expected to change respondent burden, this ICR has been characterized as a revision because the agency has reformatted elements of Form OWCP-1168 (e.g., replaced an obsolete logo with the DOL Seal, OMB Control Number, additional notice on rights for persons with disabilities, and removed references to the no longer existent Employment Standards Administration). Upon OMB's clearance of this request OWCP will update the form to show the new expiration date.

$1,507,455
No
No
No
No
No
Uncollected
Yoon Ferguson 202 693-0701 ferguson.yoon@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.
11/07/2012


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