Provider Enrollment Form

ICR 201705-1240-002

OMB: 1240-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Justification for No Material/Nonsubstantive Change
2017-06-01
Justification for No Material/Nonsubstantive Change
2016-07-05
Supporting Statement A
2016-01-22
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
IC Document Collections
IC ID
Document
Title
Status
38462 Modified
ICR Details
1240-0021 201705-1240-002
Historical Active 201606-1240-007
DOL/OWCP
Provider Enrollment Form
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/14/2017
Retrieve Notice of Action (NOA) 06/01/2017
  Inventory as of this Action Requested Previously Approved
05/31/2019 05/31/2019 05/31/2019
31,979 0 31,979
4,252 0 4,252
16,629 0 16,629

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

  80 FR 38749 07/07/2015
81 FR 9513 02/25/2016
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 31,979 31,979 0 0 0 0
Annual Time Burden (Hours) 4,252 4,252 0 0 0 0
Annual Cost Burden (Dollars) 16,629 16,629 0 0 0 0
No
No

$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.
06/01/2017


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