Note to Reviewer

NOTE TO REVIEWER

Date: December 12, 2017

Request Type: 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 change to the form:

On page 9, the following Provider Specialty Codes currently read: “58-Orthopedic Surgery” and “63-Urological Surgery” and would like them to read: “58-Orthopedic/Orthopedic Surgery” and “63-Urolgoloy/Urological Surgery”

Please see attached below:

This change does not impact the content, instructions, or the information being requested.