Provider Enrollment Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1240-0021 can be found here:

Documents and Forms

Document Name Document Type
Form OWCP-1168 Provider Enrollment Form Form and Instruction
OWCP-1168 Provider Enrollment Form 1240-0021 OWCP Provider Enrollment Form (OWCP-1168).pdf owcpmed.dol.gov/portal/main.do Form and Instruction

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 725.704 20 CFR 10.801 20 CFR 725.705 20 CFR 30.701

Information Collection Instruments:

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

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: 80 %

	Approved	Previously Approved
Annual Number of Responses for this IC	64,325	64,325
Annual IC Time Burden (Hours)	32,163	32,163
Annual IC Cost Burden (Dollars)	37,309	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.