Provider Enrollment Form

ICR 202309-1240-001

OMB: 1240-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2023-10-03
Supplementary Document
2023-09-27
Supporting Statement A
2023-09-27
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 202309-1240-001
Received in OIRA 202301-1240-005
DOL/OWCP
Provider Enrollment Form
Revision of a currently approved collection   No
Regular 10/03/2023
  Requested Previously Approved
36 Months From Approved 12/31/2023
23,318 64,325
9,716 32,163
816 37,309

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.

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

  88 FR 42104 06/29/2023
88 FR 68150 10/03/2023
No

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

  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
No
Yes
Miscellaneous Actions
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.

$429,867
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.
10/03/2023


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