Thank you for your interest in participating as a medical services provider for the four programs administered by the U.S. Department of Labor's Office of Workers' Compensation Programs (OWCP). The OWCP administers four major disability compensation programs which provide benefits to certain workers or their dependents who experience work-related injury or occupational disease. These programs include the Division of Federal Employees’ Compensation (DFEC), the Division of Energy Employees Occupational Illness Compensation (DEEOIC), the Division of Coal Mine Workers’ Compensation (DCMWC), and the Division of Longshore and Harbor Workers’ Compensation (DLHWC).
OWCP has contracted to provide medical bill processing services for these four programs. As part of their benefit structure, these programs reimburse medical and non-medical providers for services rendered for the care and treatment of a claimant’s compensable condition.
OWCP can only process bills from providers who have enrolled. To enroll, complete the enclosed provider enrollment form to be assigned a provider identification number. Instructions for completing the enrollment form and a list of provider types are enclosed. Any Provider Enrollment Form that is received with missing or incomplete information will be returned to the submitter for correction and/or completion.
The Debt Collection Improvement Act of 1996 requires that payments made by the Federal Government be sent by electronic funds transfer (EFT). EFT payments are mandatory because it simplifies the process, reduces the incidents of billing error, and allows for expedited handling. An enrollment form for EFT is enclosed. A remittance advice listing all bills paid on each EFT transaction will be sent to your mailing address. Please see notice on page 2.
You must submit current licensure information with your enrollment application. Moreover, each provider must maintain appropriate current licensure in order to receive payments under OWCP's programs.
Group practices are responsible for monitoring the licensure of each servicing provider in the practice. Where large group practices have providers in the group who are not providing medical services to our program on a regular basis, the group practice is responsible for monitoring the licensure of each provider who practices in the entire group.
You may register as a participant in any one or more of the following four OWCP compensation programs – DFEC, DEEOIC, DCMWC, and DLHWC. Please send the completed package(s)) at the address listed on the signature page (page 8) in the Form OWCP-1168.
To assist claimants seeking medical services, OWCP has an on-line listing of providers, by program that is searchable by: specialty, name, city, state, and zip code. Customers will be advised that a provider listing is not an endorsement, referral, or an agreement to reimburse for medical services rendered by the Department of Labor or OWCP. Nor does it guarantee that a medical provider will be reimbursed by OWCP for specific medical services or that a medical provider will agree to provide medical services to a particular claimant.
You will be notified by mail once your enrollment package has been processed. Once you have received your OWCP provider number, you may submit bills to the appropriate program at the following address(s):
U.S. Department of Labor OWCP/DFEC
P. O. Box 34450
San Antonio, TX 78265
U.S. Department of Labor OWCP/DEEOIC
P. O. Box 34930
San Antonio, TX 78265
U.S. Department of Labor OWCP/DCMWC
San Antonio, TX 78265
U.S. Department of Labor OWCP/DLHWC
P. O. Box 34927
San Antonio, TX 78265
If you have any questions regarding this information, please contact us at:
1-844-493-1966
Our business hours are Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time.
NOTICE: Please be aware that the information being requested on Department of Treasury SF 3881- Payment Information Form ACH Vendor Payment System - is required as part of the Department of Treasury Regulation 31 C.F.R. Part 208. This federal regulation, in part, requires that all agencies issuing federal payment do so via Electronic Fund Transfer (EFT). This includes but is not limited to the requirement of requesting a bank signature. Failure to include this information at the time the provider enrollment and ACH Payment Information forms are submitted will result in the return of these documents to the provider.
NOTICE: Continued participation as a medical provider under the four DOL programs above can be contingent on your maintaining good standing as a medical provider under other federal health benefit programs such as Medicare. Exclusion as a medical provider in those circumstances operates as an automatic exclusion under the DFEC, DEEOIC and DLHWC Programs administered by OWCP. (See 20 C.F.R. §§ 10.815, 30.715, and 702.431). You may also be subject to the federal government’s suspension and debarment provisions. (See 48 C.F.R. Subpart
9.4 and 2 C.F.R. Part 180).
U.S. Department of Labor
Office
of Workers’ Compensation Programs
Reset
OMB Number 1240-0021
Expires:
05/31/20xx
Are you applying for a new enrollment or updating your record?
New
Enrollment
Re-Enrollment
Re-Validation
Update
1a.
If Update, Re-Enrollment or Re-Validation,
Enrollment Type
Individual
Group Practice (Please
see Page 9 for completion of group
practice enrollment)
Facility/Agency/Organization/Institution
Provider Type Select
(For multi-specialty group provider, select primary provider type)
If
you select “Other Provider” (96) or Non-Medical Vendor
(53) 3a. Please explain
Program
DFEC DCMWC DEEOIC DLHWC
Individual
Information (If you enroll using SSN) 5a. Last Name
5b. First Name
5c. Middle Name
5d. SSN
Organization Information 6a. Organization Name
(Legal Business Name)
6b. Organization Business Name (Doing Business As)
6c. FEIN
I do not wish to be included in an online searchable list of OWCP providers.
10a.
Reason
Location Contact Information 11a. Business Name
11b. Contact Last Name |
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11c. Contact First Name |
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11e. Fax Number |
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11d. Phone Number |
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Physical Address
12a.
Address Line 1 Address Line 2
Address
Line 3
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12d. Zip Code |
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12b. City/Town |
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12c.State/Province |
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12f. Country |
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12e. County |
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Mailing
Address Same as
Physical
Address
13a.
Address Line 1 Address Line 2
Address Line 3
Taxonomy a. b.
Code(s)
c. d. e.
PART D: OWNERSHIP DETAILS |
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15. Organization Owner |
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15a. Organization Name |
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15b. FEIN |
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16. Individual Owner |
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16a. Last Name |
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16b. First Name |
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16c. SSN |
Address
17a.
Address Line 1 Address
Line 2
Address
Line 3
17b. City/Town |
17c. State/Province Select |
17d. Zip Code |
17e. County |
17f. Country |
Additional
Ownership Information
Organization Owner
20. Address
20a.
Address Line 1 Address
Line 2
Address
Line 3
20b. City/Town |
20c. State/Province Select |
20d. Zip Code |
20e. County |
20f. Country |
21a. License/Certification Category Select |
21b. Name |
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21d. License/Certification Number |
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21c. License/Certification Type |
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21f. Expiration Date |
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21e. Initial Issue Date |
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21g. Issued State Select |
21h. Issuer Agency |
21i.
Web Link
21j. License/Certification
not required by State.
21k.
Please explain
Additional
License/Certification
22a. License/Certification Category |
Select |
22b. Name |
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22c. License/Certification Type |
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22d. License/Certification Number |
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22e. Initial Issue Date |
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22f. Expiration Date |
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22g. Issued State Select |
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22h. Issuer Agency |
22i.
Web Link
Provider Identifier Information
23a. Identifier Type |
Select |
23b. Identifier Value |
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23d. End Date |
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23c. Start Date |
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Additional
Provider identifier
information
24a. Identifier Type |
Select |
24b. Identifier Value |
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24c. Start Date |
24d. End Date |
Mode of Submission. Check all applicable
Billing
Agent/Clearinghouse Web Batch
Web Interactive None
FTP Secured Batch
26b. Start Date |
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26c. End Date |
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Billing Agent/Clearinghouse/Submitter Information 26a. Billing Agent/Clearinghouse OWCP ID
EDI
Contact
Information
27a. Contact Title
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27c. First Name |
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27b. Last Name |
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27e. Fax Number |
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27d. Phone Number |
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27f.
Email Address
Address
28a.
Address Line 1 Address Line 2
Address
Line 3
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28d. Zip Code |
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28b. City/Town |
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28c. State/Province |
Select |
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28f. Country |
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28e. County |
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29c. First Name |
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29b. Last Name |
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29e. Fax Number |
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29d. Phone Number |
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29f.
Email Address
Address
30a.
Address Line 1 Address Line 2
Address
Line 3
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30c. State/Province |
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30d. Zip Code |
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30b. City/Town |
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Select |
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30f. Country |
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30e. County |
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Collection of this information by OWCP is necessary for its administration of the Federal Employees’ Compensation Act, the Black Lung Benefits Act, the Longshore and Harbor Workers’ Compensation Act and the Energy Employees Occupational Illness Compensation Program Act, and is authorized under 20 CFR 10.800, 20 CFR 30.700, 20 CFR 702.145, 20 CFR 725.714 and 33 USC 918(b). The information provided will be used to ensure accurate payment of medical and vocational rehabilitation provider bills and is protected by the Privacy Act of 1974, as amended (5 USC 552a) in accordance with the following systems of records: DOL/GOVT-1, DOL/OWCP-4 DOL/OWCP-9 and DOL/OWCP-11, published in the Federal Register, Vol. 81, page 25766, April 29, 2016, or as updated and republished. Completion and submission of this form is voluntary; however, failure to provide the information (including SSN or FEIN) will result in substantially delayed payment of bills. This information will be furnished to OWCP and its data processing contractors and may also be disclosed to other federal and state agencies in connection with the administration of other programs, to the Department of Justice for litigation purposes, and to medical and other provider review boards. Additional disclosures may be made through the routine uses for information contained in the referenced systems of records.
Under the Paperwork Reduction Act., persons are not required to respond to a collection of information unless such collection displays a valid OMB control number. We estimate that it will take an average of 30 minutes to complete this information collection, including time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information. If you have any comments regarding these estimates or any other aspect of this collection including suggestions for reducing this burden, send them to the U.S. Department of Labor, Office of Workers' Compensation Programs, Room S-3524, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THE ABOVE ADDRESS.
If you have a substantially limiting physical or mental impairment, Federal disability nondiscrimination law gives you the right to receive help from OWCP in the form of communication assistance, accommodation and modification to aid you in the claims process. For example, we will provide you with copies of documents in alternate formats, communication services such as sign language interpretation, or other kinds of adjustments or changes to account for the limitations of your disability. Please contact our office or the claims examiner to ask about this assistance.
Within
ten years of the date of this statement have you or any individual
listed on this application had an action related to fraud or abuse in
a government program taken against him or her resulting in (1) a
felony or misdemeanor conviction; (2) a liability finding in civil
proceedings; or (3) a settlement entered in lieu
of conviction? Yes No
If
Yes, provide details including type of action, Agency undertaking
adverse action and date of action.
For
Provider Type “Medical Supplies/Durable Medical Equipment (DME)
/ Prosthetics / Orthotics” (75) only: Are you an accredited
DMEPOS supplier enrolled with
Medicare? Yes
No
If
Yes, provide the phone number that you used in your Medicare DMEPOS
enrollment.
I, the undersigned, certify to the following: I have read the contents of this application, and the information contained herein is true, correct, and complete. I authorize the OWCP to verify the information contained herein. I agree to notify the OWCP of any change in ownership, practice location and/or Final Adverse Action involving fraud or abuse within 30 days of the reportable event. In addition, I agree to notify the OWCP of any other changes to the information in this form within 90 days of the effective date of change.
I also certify that I am not currently sanctioned, suspended, debarred or excluded by any Federal or State Health Care Program, (e.g., Medicare, Medicaid, or any other Federal program), or otherwise prohibited from providing services to Medicare, Medicaid, or other Federal program beneficiaries nor are any owners, officers, or managing employees of the practice listed in this application.
I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplying information to the Department of Labor, Office of Workers’ Compensation Program (OWCP), or any deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the denial or revocation of OWCP billing privileges, civil damages, and/or imprisonment.
I agree to abide by the OWCP regulations and program instructions that apply to me or to the organization listed in Section 3A of this enrollment form. I understand that payment of a claim by OWCP is conditioned upon the claim and the underlying transaction complying with state and federal laws (including, but not limited to, the Federal anti-kickback statute) and OWCP regulations, and program instructions.
I
have completed an ACH Vendor Payment/Electronic Fund Transfer (EFT)
form.
Print
Name and Title
Signature Date
Provider Enrollment Department of Labor - OWCP
P. O. Box 34690
San Antonio, TX 78265
Fill in this addendum to add, update or remove servicing providers for Group Practice as applicable.
Reviewer will validate NPI for all servicing providers.
Reviewer will also validate license and certificate for 9 or less servicing providers. For more than 9 providers, group is responsible for validating license and certificate.
Reset
1. 2. Individual Information (Applicable if enrolling using SSN)
Add
Update Remove
2a. Last Name
2b. First Name
2c. Middle Name
2d.
SSN
3. Organization
Information (Applicable if enrolling using
FEIN)
Taxonomy a. b. c. d. e.
License/Certification
Information
License/ Certification Category |
License/Certification Type |
License/ Certification Number |
Issued State |
Initial Issue Date |
Expiration Date |
Select |
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Select |
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Select |
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Select |
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en
se/
Additional Addendum Information3. Organization Information (Applicable if enrolling using FEIN)
7. License/Certification Information
License/ Certification Category |
License/Certification Type |
License/ Certification Number |
Issued State |
Initial Issue Date |
Expiration Date |
Select |
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Select |
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Select |
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Select |
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Type
or print additional Taxonomy information as applicable. Use
additional sheet(s) as required.
Taxonomy |
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Type
or print additional license and certification information as
applicable. Use additional sheet(s) as required
1. License/Certification Category Select |
2. Name |
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4. License/Certification Number |
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3. License/Certification Type |
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6. Expiration Date |
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5. Initial Issue Date |
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8. Issuer Agency |
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7. Issued State |
Select |
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9.
Web Link
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2. Name |
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1. License/Certification Category |
Select |
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4. License/Certification Number |
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3. License/Certification Type |
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5. Initial Issue Date |
6. Expiration Date |
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8. Issuer Agency |
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7. Issued State |
Select |
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9.
Web Link
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2. Name |
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1. License/Certification Category |
Select |
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4. License/Certification Number |
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3. License/Certification Type |
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5. Initial Issue Date |
6. Expiration Date |
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7. Issued State Select |
8. Issuer Agency |
9.
Web Link
Type or print additional Billing Agent/Clearinghouse Provider IDs as applicable. Use additional sheet(s) as required.
Billing Agent/Clearinghouse ID |
Start Date |
End Date |
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A brief description of each data element is listed below. Be sure to sign and date the form when you submit it.
Part A: Basic Information |
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1. |
Indicate whether this form is being used for a New Enrollment, to Update an existing ACTIVE enrollment record, for a Re-Enrollment (previously enrolled provider was excluded, now has become re-eligible) or to Re-Validate currently enrolled but EXPIRED enrollment record. |
Required |
1a. |
If the form is being submitted to Update, Re-Enrollment or Re-Validate your record, enter your Provider Number or Federal Employer Identification Number.
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Required if Update, Re- Enrollment or Re-Validate option is selected in 1 |
2. |
Select Enrollment Type: Individual
Group Practice
Number (Name, Social Security number, Provider Type Code from list |
Required Refer to Appendix 2 for more information |
below, NPI, DEA Number, Taxonomy, License or Certificate Type, License Number, Issue Date, Issue State and Expiration Date of current license). Continue additional sheet(s) as needed. Facility/Agency/Organization/Institution
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(NPI) available through the National Plan and Provider Enumeration System (NPPES). This provider type can include Fiscal Intermediaries, Non-Emergency Transportation, etc. |
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3. |
Type or print Provider Type For Group Practice, type or print primary Provider Type. |
Required Refer to Appendix 1 for more information |
3a. |
Type or print explanation for Provider Type |
Required if 53 or 96 is selected in 3. |
4. |
Check the Program(s) in which you want to enroll as a provider. If mailing, please mail the application to P.O. Box as indicated on Page 8 of the application or fax a separate document. |
Required Refer to Appendix 3 for more information |
5. |
Type or print Individual information |
Required if enrolled using SSN |
5a. |
Type or print provider’s Last Name |
Required |
5b. |
Type or print provider’s First Name |
Required |
5c. |
Type or print provider’s Middle Name |
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5d. |
Type or print SSN |
Required |
6. |
Type or print Organization information |
Required if enrolled using FEIN |
6a. |
Type or print Organization Name (i.e.) Legal Business Name |
Required |
6b. |
Type or print Organization Business Name (i.e.) Doing Business As |
Required |
6c. |
Type or print FEIN |
Required |
7. |
Type or print NPI |
Refer to Appendix 3 for requirements |
8. |
Type or print IRS W9 Entity Type. Select from following values:
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Required |
8a. |
Type or print Reason |
Required if selected Others in 8 |
9. |
Type or print Email Address |
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10. |
Select this option if you do not wish to be included in the OWCP online searchable program. However, selecting this option will not exclude your information in a FOIA (Freedom Of Information Act) request. |
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10a. |
Type or print Explanation |
Required if checkbox is selected in 10 |
Part B: Location Information |
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Providers offering services at different location(s) are required to enroll separately for each location. Servicing providers under a group practice are not required to enroll separately. |
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11. |
Location Contact information |
Required |
11a. |
Type or print location Business Name |
Required |
11b. |
Type or print contact Last Name |
Required |
11c. |
Type or print contact First Name |
Required |
11d. |
Type or print Phone number |
Required |
11e. |
Type or print Fax number |
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11f. |
Type or print Email Address |
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12. |
Type or print Physical Address |
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12a. |
Type or print street Address Line 1 |
Required |
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Type or print street Address Line 2 |
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Type or print street Address Line 3 |
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12b. |
Type or print City or Town |
Required |
12c. |
Type or print State or Province |
Required for domestic address |
12d. |
Type or print Zip (or postal) Code |
Required |
12e. |
Type or print County |
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12f. |
Type or print Country |
Required for foreign address |
13. |
Select this option if the mailing address is same as the physical address. Otherwise print or type Mailing Address |
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13a. |
Type or print street Address Line 1 |
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Type or print street Address Line 2 |
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Type or print street Address Line 3 |
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13b. |
Type or print City or Town |
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13c. |
Type or print State or Province |
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13d. |
Type or print Zip (or postal) Code |
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13e. |
Type or print County |
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13f. |
Type or print Country |
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Part C: Taxonomy |
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Type or print Taxonomy |
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14. |
Use Addendum 1 for taxonomy for servicing providers Use Addendum 2 for additional taxonomy codes. Use additional sheet(s) |
Refer to Appendix 3 for requirements |
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as required. |
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Part D: Ownership Details |
Part D is optional. For DFEC and DEEOIC providers, list any business with more than a 5% interest in or where involvement is at an officer, director or agent of the company. |
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15. |
Type or print Organization Ownership information |
If enrolled using FEIN |
15a. |
Type or print Organization Name |
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15b. |
Type or print FEIN |
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16. |
Type or print Individual Ownership information |
If enrolled using SSN |
16a. |
Type or print individual Last Name |
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16b. |
Type or print individual First Name |
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16c. |
Type or print SSN |
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17. |
Type or print Ownership address |
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17a. |
Type or print street Address Line 1 |
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Type or print street Address Line 2 |
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Type or print street Address Line 3 |
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17b. |
Type or print City or Town |
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17c. |
Type or print State or Province |
For domestic address |
17d. |
Type or print Zip (or postal) Code |
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17e. |
Type or print County |
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17f. |
Type or print Country |
For foreign address only |
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Section 18 to 20 are for additional ownership information, use additional sheets as required |
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18. |
Refer to instructions for Section 15 |
If additional sheets needed |
19. |
Refer to instructions for Section 16 |
If additional sheets needed |
20. |
Refer to instructions for Section 17 |
If additional sheets needed |
Part E: License and Certification |
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21. |
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Refer to Appendix 3 for requirements |
21a. |
Type or print license or certification category from following options:
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Required |
21b. |
Type or print Name |
Required |
21c. |
Type or print License or Certification Type |
Required |
21d. |
Type or print License or Certification Number |
Required |
21e. |
Type or print License or Certification Initial Issue Date |
Required |
21f. |
Type or print License or Certification Expiration Date |
Required |
21g. |
Type or print License or Certification Issued State |
Required |
21h. |
Type or print License or Certification Issuer Agency |
Required |
21i. |
Type or print License or certification Web Link |
Required |
21j. |
Select this option if License or Certification is not required by State |
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21k. |
Type or print Explanation |
Required if 25j. is selected |
22. |
Additional License and Certification information. Refer to instructions for section 21. Use additional sheet(s) as required. |
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Part F: Identifiers |
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23. |
Identifier information |
Medicare number is required for hospitals (Provider type: 01, 02, 03) |
23a. |
Type or print Identifier Value from below list of values:
|
Required |
23b. |
Type or print Identifier Value |
Required |
23c. |
Type or print Start Date |
Required |
23d. |
Type or print End Date |
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24. |
Additional Identifier information. Refer to instructions for section 23. Use additional sheet(s) as required. |
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Part G: EDI Submission Method |
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25. |
Select mode of Submission. Select all applicable options:
Billing For providers who use a 3rd party to bill. Agent/Clearinghouse
Web Interactive For entering (keying) bills directly in the System. |
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FTP Secured Batch: For submitting files via an SFTP site.
Web Batch For upload/download of files in the system.
None For submissions through paper form ONLY.
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Part H: EDI Submitter Details |
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26. |
Billing Agent/Clearinghouse information
Refer to Addendum 4 for additional information. Use additional sheet(s) as required. |
Required if Billing Agent/Clearinghouse selected in Part G |
26a. |
Type or print Billing Agent/Clearinghouse OWCP ID |
Required |
26b. |
Type or print Start Date |
Required |
26c. |
Type or print End Date |
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Part I: EDI Contact Details |
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27. |
EDI Contact information |
Required if FTP Secured Batch or Web Batch is selected in Part G |
27a. |
Type or print Contact Title |
Required |
27b. |
Type or print contact last name |
Required |
27c. |
Type or print contact First Name |
Required |
27d. |
Type or print contact Phone number |
Required |
27e. |
Type or print contact Fax number |
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27f. |
Type or print contact Email Address |
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28. |
Type or print Contact Address |
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28a. |
Type or print street Address Line 1 |
Required |
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Type or print street Address Line 2 |
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Type or print street Address Line 3 |
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28b. |
Type or print City or Town |
Required |
28c. |
Type or print State or Province |
Required for domestic address |
28d. |
Type or print Zip (or postal) Code |
Required |
28e. |
Type or print County |
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28f. |
Type or print Country |
Required for foreign address |
29. |
Additional EDI Contact information. Refer to instructions for Section 27 |
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30. |
Additional EDI Contact address. Refer to instructions for Section 28 |
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Addendum 1: Servicing Providers Information |
Required for enrollment type Group Practice |
|
1. |
Select one option to add, update or remove a servicing provider:
|
Required |
2. |
Type or print Individual information |
Required if enrolled using SSN |
2a. |
Type or print Last Name |
Required |
2b. |
Type or print First Name |
Required |
2c. |
Type or print Middle Name |
|
2d. |
Type or print SSN |
Required |
3. |
Type or print Organization information |
Required if enrolled using FEIN |
3a. |
Type or print Organization Name |
Required |
3b. |
Type or print Organization Business Name |
Required |
3c. |
Type or print FEIN |
Required |
4. |
Type or print Provider Type |
Required Refer to Appendix 1 for more information |
5. |
Type or print NPI |
Refer to Appendix 3 for requirements |
6. |
Type or print Taxonomy |
Refer to Appendix 3 for requirements |
7. |
Type or print License/Certification information |
Refer to Appendix 3 for requirements |
|
Type or print License or Certification Category from following options:
|
Required |
|
Type or print License or Certification Type |
Required |
|
Type or print License or Certification Number |
Required |
|
Type or print License or certification Issued State |
Required |
|
Type or print License or certification Initial Issue Date |
Required |
|
Type or print License or certification Expiration Date |
Required |
Supporting Documents |
Required, please attach copy of the applicable supporting document(s) |
|
|
|
|
1. |
ACH Form |
Required |
2. |
Copy of License/Certification |
Required if you provided License/Certification information in Part E |
3. |
Other Supporting Document |
|
4. |
Provider Enrollment Form Signature Page |
Required |
5. |
State Approval Letter |
If you selected License not required by state option in Part E |
01 |
General Hospital |
63 |
Optician |
02 |
Special Hospital/ Rehabilitation Facility |
65 |
Home Health Agency |
03 |
Psychiatric Hospital |
66 |
Rural Health Clinic |
05 |
Community Mental Health Center |
67 |
DMA Consult Contractor |
20 |
Pharmacy |
68 |
Federally Qualified Health Center |
25 |
Physician (MD) & Physician (DO) |
69 |
Birthing Center |
27 |
Podiatrist |
70 |
Health Maintenance Organization or |
28 |
Chiropractor |
|
Preferred Health Plan |
29 |
Physician Assistant |
71 |
Physical Therapist |
30 |
Advanced Registered Nurse Practitioner |
72 |
Occupational Therapist |
|
(ARNP) |
73 |
Pulmonary Rehabilitation |
31 |
Certified Registered Nurse Anesthetist |
74 |
Outpatient Renal Dialysis Facility |
|
(CRNA) |
75 |
Medical Supplies/Durable Medical |
32 |
Psychologist |
|
Equipment (DME) /Prosthetics/Orthotics |
33 |
Contract Medical Consultant |
76 |
Case Management Agency |
34 |
Licensed Midwife |
77 |
Social Worker |
35 |
Dentist |
78 |
Blood Bank |
36 |
Registered Nurse (RN) |
80 |
Pay-to-Intermediary |
37 |
Licensed Practical Nurse (LPN) |
88 |
Ambulatory Surgery Center |
38 |
Nursing Attendant |
89 |
Federal Facility (VA Hospital) |
40 |
Ambulance |
90 |
Skilled Nursing Facility (SNF)-Medicare |
41 |
Contract Nurse |
|
Certified & Non-Medicare Certified |
42 |
Air/Water Ambulance Company |
92 |
Intermediate Care Facility (ICF) |
43 |
Taxi |
93 |
Rural Hospital Swing Bed |
44 |
Public Transportation & Private |
94 |
Boarding House |
|
Transportation |
95 |
Insurance Company (Third party Carriers) |
46 |
Hospice |
96 |
Other Provider |
47 |
FOH-DMA Providers |
97 |
Billing Agent |
50 |
Independent Laboratory |
98 |
Lien Holder |
51 |
Portable X-Ray Company |
|
|
52 |
Alternative Medicine (e.g., Massage |
|
|
|
Therapist/Acupuncturist) |
|
|
53 |
Non-Medical Vendor |
|
|
55 |
Vocational Rehabilitation (Training, Tuition |
|
|
|
and Schools) |
|
|
56 |
Vocational Rehabilitation Counselor |
|
|
57 |
Rehabilitation Maintenance |
|
|
58 |
Assisted Re-employment |
|
|
59 |
Relocation Expenses |
|
|
60 |
Audiologist/Speech Pathologist |
|
|
61 |
Second Opinion Contractor |
|
|
62 |
Optometrist |
|
|
Appendix 2: Enrollment Type/Provider Type
Applicable provider types for each enrollment type are listed:
Enrollment Type |
Provider Type |
Individual |
25, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, 47, 50, 51, 52, 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 80, 88, 95, 96, 98 |
Group Practice |
25, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 43, 52, 60, 62, 63, 65, 66, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 96 |
Facility/Agency/Organization/Institution |
01, 02, 03, 05, 20, 40, 42, 43, 44, 46, 50, 51, 53, 55, 57, 58, 59, 65, 66, 68, 69, 70, 73, 74, 75, 76, 78, 80, 88, 89, 90, 92, 93, 94, 95, 96, 98 |
Provider Type |
NPI required? |
Taxonomy required? |
License/Certification required? |
Applicable Program(s) |
Self-Enrollment allowed? ** |
01 |
|
|
|
All |
|
02 |
|
|
|
All |
|
03 |
|
|
|
All |
|
05 |
|
|
|
All |
|
20 |
|
|
|
All |
|
25 |
|
|
|
All |
|
27 |
|
|
|
All |
|
28 |
|
|
|
All |
|
29 |
|
|
|
All |
|
30 |
|
|
|
All |
|
31 |
|
|
|
All |
|
32 |
|
|
|
All |
|
33 |
|
|
|
DEEOIC |
|
34 |
|
|
|
DFEC |
|
35 |
|
|
|
All |
|
36 |
|
|
|
All |
|
37 |
|
|
|
All |
|
38 |
|
|
|
All |
|
40 |
|
|
|
All |
|
41 |
|
|
|
DFEC |
|
42 |
|
|
|
All |
|
43 |
|
|
|
All |
|
44 |
|
|
|
All |
|
46 |
|
|
|
All |
|
Provider Type |
NPI required? |
Taxonomy required? |
License/Certification required? |
Applicable Program(s) |
Self-Enrollment allowed? ** |
47 |
|
|
|
DFEC |
|
50 |
|
|
|
All |
|
51 |
|
|
|
All |
|
52 |
|
|
|
All |
|
53 |
|
|
|
All |
for DEEOIC |
55 |
|
|
|
DFEC |
|
56 |
|
|
|
DFEC |
|
57 |
|
|
|
DFEC |
|
58 |
|
|
|
DFEC |
|
59 |
|
|
|
DFEC |
|
60 |
|
|
|
All |
|
61 |
|
|
|
All |
|
62 |
|
|
|
All |
|
63 |
|
|
|
All |
|
65 |
|
|
|
All |
|
66 |
|
|
|
All |
|
67 |
|
|
|
DFEC |
|
68 |
|
|
|
All |
|
69 |
|
|
|
All |
|
70 |
|
|
|
All |
|
71 |
|
|
|
All |
|
72 |
|
|
|
All |
|
73 |
|
|
|
All |
|
74 |
|
|
|
All |
|
75 |
|
|
|
All |
|
Provider Type |
NPI required? |
Taxonomy required? |
License/Certification required? |
Applicable Program(s) |
Self-Enrollment allowed? ** |
76 |
|
|
|
All |
|
77 |
|
|
|
All |
|
78 |
|
|
|
All |
|
80 |
|
|
|
All |
|
88 |
|
|
|
All |
|
89 |
|
|
|
All |
|
90 |
|
|
|
All |
|
92 |
|
|
|
All |
|
93 |
|
|
|
All |
|
94 |
|
|
|
All |
|
95 |
|
|
|
All |
|
96 |
|
|
|
All |
|
97 |
|
|
|
All |
|
98 |
|
|
|
All |
|
** If Self-Enrollment is not allowed for a certain provider type, please contact 1-844-493-1966.
Previous editions unusable
OWCP-1168
(Revised 00/00)
Page 1
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | OWCP |
Author | Kannabiran |
File Modified | 0000-00-00 |
File Created | 2021-01-14 |