How to complete a Provider Enrollment - Group

How to Complete a Provider Enrollment Application

GROUP PROVIDER(S)

 

How to Complete a Provider Enrollment Application

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

 

Completing an Enrollment Application

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

• •Practice Information (Section 3) 

• •All practice types (Individual/Facility/Group), must complete this section of the application. 

 

Completing an Enrollment Application
Provider Enrollment Form        - U.S. Department of Labor
Providers MUST Select a Type of Practice

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor
If the provider checked “c” for group they must complete box 12

Block 11a through Block 11c: Is NOT required for a Group Provider

 

Block 12:   The provider should check the box and type or print their SSN or EIN as appropriate. *

                  Note: If the provider is a sole proprietor they should use their SSN #

                            If the provider is an LLC, INC., etc., they should use their EIN #

Block 13a through Block 13c is NOT required for a Group Provider

Block 14a through Block 14d is NOT required for a Group Provider

* If data is missing from these fields, the application will be Returned to the Provider (RTP)

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

• •Group Provider Enrollment – 10c 

• •For group practice enrollment, please enter the following information for each professional who will provide services under the group EIN.  Select the Provider Type code (from the list attached to the application) that most closely describes the service(s) that the provides.  

 

Completing an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor
Disclosure Statement - New Addition to the Provider Enrollment Application

 

Submitting an Enrollment Application
Provider Enrollment Form - U.S. Department of Labor

For Federal Employees’ Compensation Act (FECA) Program	For Black Lung Program	For Energy Program
OWCP/FECA P.O. Box 8300 London, KY 40742-8300	DCMWC/Black Lung P.O. Box 8302 London, KY 40742-8302	DEEOIC P.O. Box 8304 London, KY 40742-8304
If you have any questions regarding the completion of the form, please call Toll Free: 1-844-493-1966	If you have any questions regarding the completion of the form, please call Toll Free: 1-800-638-7202	If you have any questions regarding the completion of the form, please call Toll Free: 1-866-272-2682

 

 

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