Provider Enrollment Form

Provider Enrollment Form

OMB: 1215-0137

IC ID: 38462

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Provider Enrollment Form
 
No Migrated
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form OWCP-1168 No No


    

13,600 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 13,600 0 1,000 0 0 12,600
Annual IC Time Burden (Hours) 1,809 0 133 0 0 1,676
Annual IC Cost Burden (Dollars) 5,000 0 0 0 0 5,000

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