Provider Enrollment Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OWCP-1168 Provider Enrollment Form	Form and Instruction	Modified	Available
SS 1215-0137 June 2006.doc	Supporting Statement A	Uploaded 2006-10-31	Available
Regulations for BLBA, EEOICPA, FECA, and LHWCA.doc	Supplementary Document	Uploaded 2006-10-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
38462	Provider Enrollment Form	Form and Instruction	Modified

ICR Details

OMB Control No: 1215-0137	ICR Reference No: 200610-1215-005
Status: Historical Active	Previous ICR Reference No: 200506-1215-005
Agency/Subagency: DOL/ESA	Agency Tracking No:
Title: Provider Enrollment Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/09/2007
	Date Received in OIRA: 11/08/2006
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2010	36 Months From Approved	03/31/2007
Responses	48,242	0	13,600
Time Burden (Hours)	6,417	0	1,809
Cost Burden (Dollars)	17,736	0	5,000

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Abstract: 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.

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Authorizing Statute(s): US Code: 5 USC 8101 Name of Law: The Federal Employees' Compensation Act (FECA)
   US Code: 30 USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
   US Code: 42 USC 7384 Name of Law: The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 33 USC 901 Name of Law: The Longshore and Harbor Workers' Compensation Act (LHWCA)
  

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:
	71 FR 40737	07/18/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 65545	11/08/2006
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

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

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ICR Summary of Burden

table that charts list of burden

	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	48,242	13,600	0	0	34,642	0
Annual Time Burden (Hours)	6,417	1,809	0	0	4,608	0
Annual Cost Burden (Dollars)	17,736	5,000	0	0	12,736	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: No

Burden Reduction Due to:

Short Statement: Since the bulk of providers enrolled in the four programs were required to re-enroll with current information, Form OMB 83-I shows an adjusment of +4608 burden hours and +$15,262 operational and maintenance costs.

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Annual Cost to Federal Government: $1,276,477

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

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 11/08/2006

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