Provider Enrollment Form

Provider Enrollment Form

OMB: 1240-0021

IC ID: 38462

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Information Collection (IC) Details

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Provider Enrollment Form
 
No Modified
 
Voluntary
 
20 CFR 10.801 20 CFR 725.704 20 CFR 30.701 20 CFR 725.705

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability

Health Illness Prevention

DOL/GOVT-1(for FECA); DOL/OWCP-2(for BLBA); AND DOL/OWCP-11 (for EEOICPA)  81 FR 25766

64,325 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 64,325 0 0 0 0 64,325
Annual IC Time Burden (Hours) 32,163 0 0 0 0 32,163
Annual IC Cost Burden (Dollars) 37,309 0 0 0 0 37,309

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