Addendum to ICR submission

Justification -OWCP 1168 Provider Enrollment Form.docx

Provider Enrollment Form

Addendum to ICR submission

OMB: 1240-0021

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Justification for No material/Nonsubstantive Change

OWCP 1168 Provider Enrollment Form (OWCP-1168/PE-1168)



The Department of Labor’s Office of Workers’ Compensation Programs (OWCP) is the agency responsible for administration of the Federal Employees’ Compensation Act (FECA), 5 U.S.C. 8101 et. seq., the Black Lung Benefits Act (BLBA), 30 U.S.C. 901 et. seq. and the Energy Employees’ Occupational Illness Compensation Program Act of 2000 (EEOICPA), 42 U.S.C. 7384 et. seq.  These statutes require OWCP to pay for appropriate medical and vocational rehabilitation services provided to beneficiaries. OWCP is requesting an address change to OWCP billing form OWCP-1168, Provider Enrollment Form as the OWCP medical bill processor has procured a new mailroom and requires a means to receive medical bills and other forms from medical providers.


Approval of this request is needed by October 1, 2020 for posting of the form on the medical bill processors web portal. This will allow ample time for the bill processor’s assumption of operations. Any approval date beyond October 1, 2020 would necessitate a delay in operations until the request is approved.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorSuggs, Anjanette C - OWCP
File Modified0000-00-00
File Created2021-01-13

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