How to complete a Provider Enrollment - Group

How to Complete a Provider Enrollment Application - Group.pptm

Provider Enrollment Form

How to complete a Provider Enrollment - Group

OMB: 1240-0021

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How to Complete a Provider Enrollment Application

GROUP PROVIDER(S)

 

How to Complete a Provider Enrollment Application

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor



 

Completing an Enrollment Application

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor


  • Practice Information (Section 3) 

  • All practice types (Individual/Facility/Group), must complete this section of the application. 

 

Completing an Enrollment Application
Provider Enrollment Form        - U.S. Department of Labor
Providers MUST Select a Type of Practice


 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor
If the provider checked “c” for group they must complete box 12



Block 11a through Block 11c: Is NOT required for a Group Provider

 

Block 12:   The provider should check the box and type or print their SSN or EIN as appropriate. *

                  Note: If the provider is a sole proprietor they should use their SSN #

                            If the provider is an LLC, INC., etc., they should use their EIN #

Block 13a through Block 13c is NOT required for a Group Provider

Block 14a through Block 14d is NOT required for a Group Provider

* If data is missing from these fields, the application will be Returned to the Provider (RTP)

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

  • Group Provider Enrollment – 10c 

  • For group practice enrollment, please enter the following information for each professional who will provide services under the group EIN.  Select the Provider Type code (from the list attached to the application) that most closely describes the service(s) that the provides.  

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor
Disclosure Statement - New Addition to the Provider Enrollment Application

 

Submitting an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

For Federal Employees’ Compensation Act (FECA) Program

 

For Black Lung Program

For Energy Program

OWCP/FECA

P.O. Box 8300

London, KY

40742-8300

 

 

DCMWC/Black Lung

P.O. Box 8302

London, KY

40742-8302

DEEOIC

P.O. Box 8304

London, KY

40742-8304

If you have any questions regarding the completion of the form, please call Toll Free: 1-844-493-1966

If you have any questions regarding the completion of the form, please call Toll Free: 1-800-638-7202

 

If you have any questions regarding the completion of the form, please call Toll Free: 1-866-272-2682

 

 

 
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