Provider Enrollment Form

ICR 202007-1240-002

OMB: 1240-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2020-11-03
Supplementary Document
2020-09-26
Supporting Statement A
2020-09-23
Supplementary Document
2020-09-22
Supplementary Document
2020-09-22
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 202007-1240-002
Active 202004-1240-004
DOL/OWCP
Provider Enrollment Form
Extension without change of a currently approved collection   No
Regular
Approved without change 12/30/2020
Retrieve Notice of Action (NOA) 09/23/2020
  Inventory as of this Action Requested Previously Approved
12/31/2023 36 Months From Approved 12/31/2020
64,325 0 64,325
32,163 0 32,163
37,309 0 37,309

This ICR seeks approval under the PRA for revisions to the Provider Enrollment Form (Form OWCP-1168). The form 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. In addition to the enrollment form information collection, the OWCP bill processing contractor currently collects electronic data interchange (EDI) information from the provider only if the provider chooses a data exchange submission method.

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

  85 FR 11119 02/26/2020
85 FR 59328 09/21/2020
No

1
IC Title Form No. Form Name
Provider Enrollment Form OWCP-1168 Provider Enrollment Form

  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 64,325 64,325 0 0 0 0
Annual Time Burden (Hours) 32,163 32,163 0 0 0 0
Annual Cost Burden (Dollars) 37,309 37,309 0 0 0 0
No
No

$1,864,692
No
    Yes
    Yes
No
No
No
No
Anjanette Suggs 202 354-9660 suggs.anjanette@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.
09/23/2020


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