Provider Enrollment Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0021 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-1168 Provider Enrollment Form Form and Instruction
OWCP-1168 Provider Enrollment Form OWCP-1168.pdf owcp.dol.acs-inc.com/portal/formsAndLinks.do Form and Instruction
OWCP-1168 Web vers Provider Enrollment For, Screen Shots Screen Shots of Billing Contractor's Web Portal.pdf owcp.dol.acs-inc.com/portal/formsAndLinks.do Form and Instruction

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 30.701 20 CFR 725.704 20 CFR 10.801 20 CFR 725.705

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	OWCP-1168	Provider Enrollment Form	OWCP-1168.pdf	http://owcp.dol.acs-inc.com/portal/formsAndLinks.do	Yes	No	Fillable Printable
Form and Instruction	OWCP-1168 Web version screen shots	Provider Enrollment For, Screen Shots	Screen Shots of Billing Contractor's Web Portal.pdf	http://owcp.dol.acs-inc.com/portal/formsAndLinks.do	Yes	Yes	Fillable Fileable Signable

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: 31,979	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	Previously Approved
Annual Number of Responses for this IC	31,979	31,979
Annual IC Time Burden (Hours)	4,252	4,252
Annual IC Cost Burden (Dollars)	16,629	16,629

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.