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Provider Enrollment Form
Provider Enrollment Form
OMB: 1240-0021
IC ID: 38462
OMB.report
DOL/OWCP
OMB 1240-0021
ICR 202004-1240-004
IC 38462
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0021 can be found here:
2023-10-03 - Revision of a currently approved collection
2023-01-20 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Provider Enrollment Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Voluntary
CFR Citation:
20 CFR 10.801
20 CFR 725.704
20 CFR 30.701
20 CFR 725.705
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Illness Prevention
Privacy Act System of Records
Title:
DOL/GOVT-1(for FECA); DOL/OWCP-2(for BLBA); AND DOL/OWCP-11 (for EEOICPA)
FR Citation:
81 FR 25766
Number of Respondents:
64,325
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
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
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.