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Provider Enrollment Form
Provider Enrollment Form
OMB: 1215-0137
IC ID: 38462
OMB.report
DOL/ESA
OMB 1215-0137
ICR 200906-1215-001
IC 38462
( )
Documents and Forms
Document Name
Document Type
Form OWCP-1168
Provider Enrollment Form
Form
OWCP-1168 Provider Enrollment Form
OWCP-1168_revised draft (8-28-09).pdf
//owcp.dol.acs-inc.com/portal/formsAndLinks.do
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Provider Enrollment Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
20 CFR 725.704
20 CFR 725.705
20 CFR 30.701
20 CFR 10.801
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
OWCP-1168
Provider Enrollment Form
OWCP-1168_revised draft (8-28-09).pdf
http>//owcp.dol.acs-inc.com/portal/formsAndLinks.do
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
DOL/GOVT-1(for FECA); DOL/ESA-6(for BLBA); AND DOL/ESA-49 (for EEOICPA)
FR Citation:
67 FR 16826
Number of Respondents:
70,185
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
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
70,185
0
0
21,943
0
48,242
Annual IC Time Burden (Hours)
9,335
0
0
2,918
0
6,417
Annual IC Cost Burden (Dollars)
32,987
0
0
15,251
0
17,736
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
