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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