Provider Enrollment Form

ICR 200506-1215-005

OMB: 1215-0137

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
38462 Migrated
ICR Details
1215-0137 200506-1215-005
Historical Active 200312-1215-004
DOL/ESA
Provider Enrollment Form
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 06/29/2005
Retrieve Notice of Action (NOA) 06/29/2005
  Inventory as of this Action Requested Previously Approved
03/31/2007 03/31/2007 03/31/2007
13,600 0 12,600
1,809 0 1,676
5,000 0 5,000

Form OWCP-1168 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.

None
None


No

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

  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 13,600 12,600 0 1,000 0 0
Annual Time Burden (Hours) 1,809 1,676 0 133 0 0
Annual Cost Burden (Dollars) 5,000 5,000 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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.
06/29/2005


© 2024 OMB.report | Privacy Policy