Information Collection Request
Provider Enrollment Form
ICR 202301-1240-005 · OMB 1240-0021 · Active
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 1240-0021 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form OWCP-1168 Provider Enrollment Form |
Form and Instruction | Modified | Available |
| Form OWCP-1168 Provider Enrollment Form |
Form and Instruction | Modified | Repair queued |
 Justification-OWCP 1168 Provider Enrollment Form_20230120.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-01-20 | Repair queued |
| Justification-OWCP 1168 Provider Enrollment Form_20230120.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2023-01-20 | Repair queued |
| Justification -OWCP 1168 Provider Enrollment Form.docx |
Supplementary Document | Uploaded 2020-11-03 | Available |
| Justification -OWCP 1168 Provider Enrollment Form.docx |
Supplementary Document | Uploaded 2020-11-03 | Available |
 30-day FRN (1218-0108) published.pdf |
Supplementary Document | Uploaded 2020-09-26 | Available |
| 30-day FRN (1218-0108) published.pdf |
Supplementary Document | Uploaded 2020-09-26 | Repair queued |
| Supporting Statement 1240-0021 OWCP 1168 2020.docx |
Supporting Statement A | Uploaded 2020-09-23 | Available |
| Supporting Statement 1240-0021 OWCP 1168 2020.docx |
Supporting Statement A | Uploaded 2020-09-23 | Missing upstream |
| 30-day FRN (1240-0021) published.pdf |
Supplementary Document | Uploaded 2020-09-22 | Available |
| 30-day FRN (1240-0021) published.pdf |
Supplementary Document | Uploaded 2020-09-22 | Missing upstream |
| 60-day FRN (1240-0021) published.pdf |
Supplementary Document | Uploaded 2020-09-22 | Available |
| 60-day FRN (1240-0021) published.pdf |
Supplementary Document | Uploaded 2020-09-22 | Missing upstream |
| 20 CFR 725.704 and 705 BLBA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Available |
| 20 CFR 725.704 and 705 BLBA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Repair queued |
| 20 CFR 30.701 EEOICPA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Available |
| 20 CFR 30.701 EEOICPA Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Repair queued |
| 20 CFR 10.801 FECA - Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Available |
| 20 CFR 10.801 FECA - Supporting Reg.pdf |
Supplementary Document | Uploaded 2012-11-05 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 38462 |  Provider Enrollment Form |
Form and Instruction | Modified | |
| 38462 | Provider Enrollment Form |
Form and Instruction | Modified |
ICR Details
| Status | Active |
|---|---|
| Agency/Subagency | DOL/OWCP |
| OMB Control No | 1240-0021 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202007-1240-002 |
| Date Submitted to OIRA | 2023-01-20 |
| Requested Expiration Date | 1969-12-31 |