Provider Enrollment Form

Forms and Documents

Document Name	Status
Form OWCP-1168 Provider Enrollment Form Form and Instruction	Modified
30-day FRN_1240-0021.pdf Supplementary Document	2023-10-03
60 day FRN 20230629.pdf Supplementary Document	2023-09-27
Supporting Statement 1240-0021 OWCP 1168 2023 _20230927_FINAL.docx Supporting Statement A	2023-09-27
20 CFR 725.704 and 705 BLBA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 30.701 EEOICPA Supporting Reg.pdf Supplementary Document	2012-11-05
20 CFR 10.801 FECA - Supporting Reg.pdf Supplementary Document	2012-11-05

IC Document Collections

IC ID	Document Title	Status
38462	Provider Enrollment Form Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0021	ICR Reference No: 202309-1240-001
Status: Received in OIRA	Previous ICR Reference No: 202301-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Provider Enrollment Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 10/03/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2023
Responses	23,318	64,325
Time Burden (Hours)	9,716	32,163
Cost Burden (Dollars)	816	37,309

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Abstract: OWCP currently requires all service providers to submit all required medical licenses and the additional attestation language requires providers to further affirm that that they possess all appropriate state, county, locality, or jurisdictional business licenses to provide services to OWCP claimants. Together, these changes will reduce the complexity of the form for the form filler, without adding any additional fillable fields.

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Authorizing Statute(s): 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)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 42104	06/29/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 68150	10/03/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

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

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ICR Summary of Burden

	Total Request	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	23,318	64,325	0	-17,689	-23,318	0
Annual Time Burden (Hours)	9,716	32,163	0	-12,730	-9,717	0
Annual Cost Burden (Dollars)	816	37,309	0	393,374	-429,867	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Minor changes to the form instructions reduced respondent burden from 30 to 25 minutes. Additionally, with the April 2020 change to a new medical processing contractor, current providers were rolled over into the new system without having to complete a new Form OWCP-1168. This change reduced the number of respondents from 64,325 to 23,318, a decrease of 41,007. This resulted in an equivalent decrease in number of responses and attendant decreases to the total respondent burden hours and cost to the federal government. The previously approved number for burden hours was 32,162.5 and the requested number now is 9,717, a decrease of 22,445.5 hours. The previous cost to the federal government was $579,568 and is now $429,867, a decrease of $149,701. Additionally, since enrollment processing time is reduced when providers opt to complete the form online, very few new providers print and mail form 1168, which resulted in reduced cost to respondents. The previous approved annual cost to respondents was $24,997, and the cost requested now is $816, a decrease of $24,181.

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Annual Cost to Federal Government: $429,867

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/03/2023

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