Provider Enrollment Form

Provider Enrollment Form

OMB: 1240-0021

IC ID: 38462

Information Collection (IC) Details

View Information Collection (IC)

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

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction OWCP-1168 Provider Enrollment Form 1240-0021 OWCP Provider Enrollment Form (OWCP-1168).pdf https://owcpmed.dol.gov/portal/main.do Yes No Fillable Fileable

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
 
   80 %

  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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