How to Complete a Provider Enrollment Application - Facility

How to Complete a Provider Enrollment Application

FACILITY PROVIDER

 

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 “b” for facility, they must complete boxes 11a through 12.  

 

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

If the provider checked “b” for facility, they must complete boxes 14a through 15d.

 

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

If the provider checked “b” for facility, they must complete 17a through 20. *The provider MUST sign and date the enrollment application or it will be returned to provider and will NOT be processed

 

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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