Notice to Reviewer

NOTICE TO REVIEWER

Date: June 28, 2016

Request Type:  No material or non-substantive change to a currently approved collection

Employing Agency: Office of Workers’ Compensation Programs (OWCP)

Form Number/Name: OWCP-1168, Provider Enrollment Form

OMB/Expiration Date: 1240-0021, May 31, 2019

Justification:

We need to make minor changes to the form: incorrect telephone number provided in the intro and the form. Also add the missing Specialty Code list that should follow the list of Provider/Hospital Type Code List.  

The attached PDF has them marked by number, except for #3 which is the Provider Specialty Code List.

1. On the letter: top of page 2 that begins “… If you have any questions…”. The telephone number is incorrect. Correct telephone number is: 1-844-493-1966.

2. On page 2 of the form itself, where the program address appears: The telephone numbers listed for each program are incorrect. The correct telephone number for all 3 programs: 1-844-493-1966.

3. The page that is attached here (Provider Specialty) needs to appear as page 7 (after the list of provider/Hospital type codes and before the ACH vendor Payment application

These changes do not impact the content, instructions, or the information being requested