Provider Enrollment Form

ICR 201507-1240-001

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
2015-11-04
IC Document Collections
IC ID
Document
Title
Status
38462 Modified
ICR Details
1240-0021 201507-1240-001
Historical Inactive 201207-1240-004
DOL/OWCP
Provider Enrollment Form
Revision of a currently approved collection   No
Regular
Comment filed on proposed rule and continue 01/19/2016
Retrieve Notice of Action (NOA) 11/18/2015
In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.
  Inventory as of this Action Requested Previously Approved
01/31/2016 36 Months From Approved 05/31/2016
53,934 0 53,934
7,174 0 7,174
25,888 0 25,888

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: 42 USC 7384 Name of Law: The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   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)
  
None

1240-AA08 Proposed rulemaking 80 FR 72296 11/18/2015

  80 FR 38749 07/07/2015
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

No
No
There has been a decrease in the number of respondents seeking to provide medical or vocational services to beneficiaries. Accordingly, the burden hours decreased from 7,174 to 4,252, an adjustment of 2,922 hours and the operational and maintenance costs decreased from $25,888 to $16,629, an adjustment of $9,259.

$925,685
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.
11/18/2015


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