Provider Enrollment Form

ICR 201901-1240-002

OMB: 1240-0021

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supplementary Document
2019-03-20
Supplementary Document
2019-03-20
Supplementary Document
2019-03-20
Supplementary Document
2019-03-20
Supporting Statement A
2019-01-25
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
Supplementary Document
2012-11-05
IC Document Collections
IC ID
Document
Title
Status
38462 Modified
ICR Details
1240-0021 201901-1240-002
Historical Active 201805-1240-004
DOL/OWCP
Provider Enrollment Form
Revision of a currently approved collection   No
Regular
Approved with change 04/10/2019
Retrieve Notice of Action (NOA) 02/13/2019
  Inventory as of this Action Requested Previously Approved
06/30/2021 06/30/2021 06/30/2021
64,325 0 64,325
8,555 0 8,555
33,449 0 33,449

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.

US Code: 42 USC 7384 Name of Law: The Energy Employees Occupational Illness Compensation Program Act of 2000 (EEOICPA)
   US Code: 30 USC 901 Name of Law: The Black Lung Benefits Act (BLBA)
   US Code: 5 USC 8101 Name of Law: The Federal Employees' Compensation Act (FECA)
  
None

1240-AA08 Final or interim final rulemaking 84 FR 3026 02/08/2019

  80 FR 72296 11/18/2015
80 FR 72296 11/18/2015
No

1
IC Title Form No. Form Name
Provider Enrollment Form OWCP-1168 Provider Enrollment Form

  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 64,325 64,325 0 0 0 0
Annual Time Burden (Hours) 8,555 8,555 0 0 0 0
Annual Cost Burden (Dollars) 33,449 33,449 0 0 0 0
No
No

$1,862,106
No
    Yes
    Yes
No
No
No
Uncollected
Yoon Ferguson 202 693-0701 [email protected]

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/13/2019


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